Pediatric Hyperglycemia and Diabetic Ketoacidosis (DKA)

Pediatric Hyperglycemia and Diabetic Ketoacidosis (DKA)
Third Edition, 2015 Welcome to the Pediatric Hyperglycemia and Diabetic Ketoacidosis educational module. Illinois EMSC is a collaborative program between the Illinois Department of Public Health and Loyola University Chicago. Development of this presentation was supported in part by: Grant 5 H34 MC from the Department of Health and Human Services Administration, Maternal and Child Health Bureau

Today, almost a century after the discovery of insulin, the most common cause of death in a child with diabetes, from a global perspective, is lack of access to insulin or improper use of insulin. Many children die even before their diabetes is diagnosed. Around the world, forces have united to make it come true that no child should die from diabetes or its complications. Childhood diabetes is becoming a world wide health issue. Statistics available at the time of this publication indicate that type 1 diabetes is growing globally at 3 percent per year in children and adolescents, and at an alarming 5 percent per year among children five years of age and younger. In addition, type 2 diabetes, once known as an adult disease, is growing rapidly among children worldwide. Almost a century after the discovery of insulin, the most common cause of death in a child with diabetes from a global perspective is lack of access to insulin or improper use of insulin. Many of these children die even before their diabetes is diagnosed. Around the world, forces have united to ensure that no child should die from diabetes or its complications. With these issues in mind, Illinois Emergency Medical Services for Children, known as EMSC, has developed this educational module to provide information on diabetes and help to address the rising episodes of hyperglycemia and diabetic ketoacidosis that are being seen in health care settings within our own state. (SOURCE: Atlas International Diabetes Federation, 2003 & EURODIAB Ace Study Group, 2000)

Illinois Emergency Medical Services for Children (EMSC)
Illinois EMSC is a collaborative program between the Illinois Department of Public Health and Loyola University Chicago, aimed at improving pediatric emergency care within our state. Since 1994, Illinois EMSC has worked to enhance and integrate: Pediatric education Practice standards Injury prevention Data initiatives Illinois EMSC is a collaborative initiative between the Illinois Department of Public Health and Loyola University Health System, aimed at improving pediatric emergency care within our state. Since 1994, the Illinois EMSC Advisory Board, and several committees, organizations and individuals within EMS and pediatric communities have worked to enhance and integrate the pediatric component within our state emergency medical services system. Areas of focus include: education, practice standards, injury prevention, and data initiatives. The overall goal of Illinois EMSC is to ensure that appropriate emergency medical care and resources are available for all ill and injured children at every point along the continuum of care. Please note that this educational activity is being presented without the provision of commercial support and without bias or conflict of interest from the planners and presenters. This educational activity is being presented without the provision of commercial support and without bias or conflict of interest from the planners and presenters.

Goals Define and explain pediatric hyperglycemia and DKA
Highlight current standards of care regarding pediatric hyperglycemia and DKA management Provide educational resources to health care professionals to share with pediatric patients and families dealing with issues related to pediatric hyperglycemia and DKA It’s important to note that throughout this module, we will refer to the condition of Diabetic Ketoacidosis by the acronym DKA. To address some of the critical issues surrounding pediatric hyperglycemia and DKA, Illinois EMSC has developed this educational module with the following goals in mind: To define and explain pediatric hyperglycemia and DKA. To highlight current standards of care regarding pediatric hyperglycemia and DKA management. To provide educational resources to health care professionals to share with pediatric patients and families dealing with issues related to pediatric hyperglycemia and DKA.

Carolynn Zonia, DO, FACOEP, FACEP
Acknowledgements NOTE: This module is a revision of the original resource published in October 2012. EMSC Quality Improvement Subcommittee EMSC Facility Recognition Committee Susan Fuchs, MD, FAAP, FACEP Chair, EMSC Quality Improvement Subcommittee Ann & Robert H. Lurie Children’s Hospital of Chicago Carolynn Zonia, DO, FACOEP, FACEP Chair, EMSC Facility Recognition Committee Loyola University Health System Paula Atteberry, RN, BSN Illinois Department of Public Health Joseph R. Hageman, MD, FAAP NorthShore University Health System - Evanston Cheryl Lovejoy, RN, TNS Advocate Condell Medical Center Linnea O’Neill, RN, MPH Weiss Memorial Hospital Cathleen Shanahan, RN, BSN, MS Ann & Robert H. Lurie Children’s Hospital of Chicago Maureen Bennett, RN, BSN Loyola University Health System Sandy Hancock, RN, MS Saint Alexius Medical Center Evelyn Lyons, RN, MPH Illinois Department of Public Health S. Margaret Paik MD, FAAP University of Chicago Comer Children’s Hospital Herbert Sutherland, DO, FACEP Central DuPage Hospital Mark Cichon, DO, FACOEP, FACEP Loyola University Health System Sheri Hey, RN, BSN Edward Hospital Patricia Metzler, RN, TNS, SANE-A Carle Foundation Hospital Parul Soni, MD, MPH, FAAP John Underwood , DO, FACEP SwedishAmerican Hospital Kristine Cieslak, MD, FAAP Central DuPage Hospital Kathy Janies, BA Illinois EMSC Beth Nachtsheim-Bolick, RN, MS, APRN, CPNP-AC Rush University Anita Pelka, RN University of Chicago Comer Children’s Hospital LuAnn Vis RN, MSOD, CPHQ The Joint Commission Jacqueline Corboy, MD, FAAP Northwest Community Hospital Cindi LaPorte, RN Loyola University Health System Charles Nozicka, DO, FAAP, FAAEM Advocate Condell Medical Center Anne Porter, PhD, RN, CPHQ Lewis University Leslie Flament, RN, BSN Advocate Good Shepherd Hospital Donald Davison, MD Carle Foundation Hospital Dan Leonard, MS, MCP Illinois EMSC Laura Prestidge, RN, BSN, MPH Illinois EMSC Beverly Weaver, RN, MS Northwestern Lake Forest Hospital Leslie Foster, RN, BSN OSF Saint Anthony Medical Center Jammi Likes, RN, BSN, NREMT-P Herrin Hospital J. Thomas Senko, DO, FAAP John H. Stroger Jr. Hospital of Cook County This educational module was developed by Illinois EMSC committees. If you wish to cite any of the materials contained in this module, citation information is listed on this slide. Any information presented in this module may be used freely provided appropriate acknowledgement is cited. Finally, nothing in the module should be considered a replacement of prudent and cautious judgment of the health care provider treating a child. Every situation is unique and requires individualized care and independent treatment options. Suggested Citation: Illinois Emergency Medical Services for Children (EMSC), Pediatric Hyperglycemia and DKA, February 2015

Table of Contents Introduction Assessment Management Complications
Patient Education Resources Test Your Knowledge References Appendices Appendix A: Assessment Tools Appendix B: “Two-bag System” Appendix C: Treatment Guidelines This table of contents provides a snapshot of the sections that will be reviewed in this module.

INTRODUCTION Return to Table of Contents
Let’s begin with some background information on DKA. Return to Table of Contents

Purpose The purpose of this educational module is to enhance the care of pediatric patients who present with hyperglycemia and diabetic ketoacidosis (DKA) through appropriate: ASSESSMENT MANAGEMENT PREVENTION OF COMPLICATIONS DISPOSITION PATIENT & PARENT/CAREGIVER EDUCATION This module is designed to help you, as an emergency care professional, appropriately assess, manage, and disposition your patients who present with hyperglycemia and DKA. Information related to appropriate education of patients and their family members is also included. In addition, the module reviews how to recognize and manage potential complications, and provides links to useful resources. It is intended to be used by all health care practitioners who care for pediatric patients.

Objectives At the end of this module you will be able to:
Describe the mechanisms of hyperglycemia and DKA Perform an initial assessment on a child who is experiencing hyperglycemia and DKA Describe the clinical presentation of a pediatric patient with DKA Understand the physiologic changes taking place in a pediatric patient with DKA Develop an effective management plan Discuss cerebral edema as a complication of pediatric DKA Develop a plan for appropriate admission, transfer or referral Formulate appropriate discharge instructions Now, let’s review the main objectives of this education. Upon completion, you will be able to describe the mechanisms of hyperglycemia and DKA, perform an initial assessment, know the clinical signs and symptoms, create an effective management plan, become familiar with common complications, utilize appropriate admission, transfer and or referral guidelines, and provide appropriate education to your patients and families.

Main Resources The following publications were the primary sources of
information for this module, and will be referenced throughout: The American Diabetes Association (ADA)1 Diabetic Ketoacidosis in Infants, Children, and Adolescents A consensus statement from the American Diabetes Association European Society for Paediatric Endocrinology (ESPE)2 Lawson Wilkins Pediatric Endocrine Society (LWPES)2 European Society for Paediatric Endocrinology / Lawson Wilkins Pediatric Endocrine Society Consensus Statement on Diabetic Ketoacidosis in Children and Adolescents International Society for Pediatric and Adolescent Diabetes (ISPAD)3 Diabetic Ketoacidosis in Children and Adolescents with Diabetes ISPAD Clinical Practice Consensus Guidelines 2009 Compendium The following publications were the primary sources of information and have been adapted for this module. They include: The American Diabetes Association, European Society for Paediatric Endocrinology, Lawson Wilkins Pediatric Endocrine Society, and the International Society for Pediatric and Adolescent Diabetes. These organizations have developed published guidelines for the treatment of children with DKA and these guidelines are considered the gold standards for management.

Frequency of DKA DKA occurs in children with:
New-onset of type 1 diabetes mellitus Established type 1 diabetes mellitus during risk episodes May occur in children with type 2 diabetes mellitus In the United States, alarming numbers of children with type 1 diabetes present with potentially life threatening DKA. It’s important to note that DKA occurs frequently in children with new-onset of type 1 diabetes mellitus and may occur in children with established type 1 diabetes mellitus during risk episodes. With the incidence of type 2 diabetes mellitus increasing in children, DKA episodes may be seen occasionally in these children.

DKA Risk Factors Young children Poor diabetes control
Previous episodes of DKA Missed insulin injections Insulin pump failure Infection or other illnesses Low socioeconomic status Lack of adequate health insurance Psychiatric disorders (i.e., eating disorders) Why should we be concerned? Despite major advances in the care of diabetes, DKA remains a leading cause of hospitalization and death in children with diabetes. Annual hospitalization rates for DKA are increasing yearly. DKA accounts for 65% of all admissions and for more than 50% of childhood deaths from diabetes. Let’s look at some precipitating factors for DKA and learn why we should be concerned. In children with established diabetes, factors include: poor diabetes control, previous episodes of DKA, missed insulin injections, insulin pump failure, infection or other illnesses, low socioeconomic status, lack of adequate health insurance, and psychiatric disorders such as eating disorders. In addition, in children with new-onset diabetes, symptoms of diabetes in very young children are more difficult to recognize.

Illinois EMSC Statewide DKA QI
DKA record review (532 records total) - high percentage of cases reported documentation of: full set of vital signs, blood glucose level, and neurological status during initial assessment However, documentation of ongoing/hourly ED monitoring for same indicators was much less consistent Percentage of documentation even lower for hospitals that (on survey) reported ED ongoing monitoring was “not defined in policy” or performed “per physician decision” In 2010, over 100 emergency departments participated in a statewide quality improvement initiative. Participants responded to a survey of general practices and two DKA-based case scenarios. In addition, participants reviewed over 500 pediatric DKA patient records to determine if the careprovided was in line with current best practices. Based on input from a wide range of individuals and organizations, Illinois EMSC determined a strong need to improve the emergency care for pediatric patients presenting with hyperglycemia or DKA. Analysis of the record review data showed a high percentage of documentation during the initial assessment including: full set of vital signs, blood glucose level, and neurological status. However, documentation of ongoing or hourly ED monitoring of the same three indicators was substantially less consistent. This trend was even more pronounced for hospitals that reported that their ED monitoring was not defined in a policy or was performed per physician decision.

Illinois EMSC Statewide DKA QI
** Additional findings from the statewide QI project (responses to survey and case scenarios) seem to indicate concerning deviations from the current treatment guidelines for pediatric DKA patients within the first hour of treatment** Practice Deviations (within 1st hour of treatment) Guideline Recommendations Administer an IV fluid bolus mL/kg 0.45% NaCl over the first hour The recommended fluid course is mL/kg 0.9% NaCl over the first hour Administer an IV insulin drip of 0.1 units/kg/hour Current guidelines recommend administering insulin after the initial fluid resuscitation, not concurrently Administer an IV insulin bolus of 0.1 units/kg Current guidelines suggest IV insulin bolus may increase the risk of cerebral edema, and should not be used at the start of therapy Wait for more laboratory results before giving any fluids Current guidelines recommend initial IV fluid administration should begin immediately Results from the survey and pediatric DKA case scenarios reveal some potential practice variations that deviate from current guidelines. In particular, the case scenario responses included notable percentages of these “less than optimal” practices.

Understanding Diabetes
Diabetes mellitus, often referred to simply as diabetes. Diabetes is a condition in which the body: Does not produce enough insulin, and/or Does not properly respond to insulin To truly understand the mechanism and actions of DKA, one must understand the disease process of diabetes mellitus, often referred to simply as diabetes. Diabetes is a condition in which the body either does not produce enough insulin, and/or does not properly respond to it. Simply defined, insulin is a hormone produced in the pancreas that enables cells to absorb glucose in order to turn it into energy. Insulin is a hormone produced in the pancreas. Insulin enables cells to absorb glucose in order to turn it into energy.

Diabetes: An Epidemic Genetics Environmental factors Obesity
The cause of diabetes in children continues to be a mystery. Genetics Environmental factors Obesity Lack of exercise Overall, diabetes is seen as an epidemic. The cause of diabetes in children today continues to be a mystery. Both genetics and environmental factors have always played a role. Currently, it appears that obesity and lack of exercise play major roles. In the United States, more than 150,000 children and adolescents have diabetes mellitus. Each year, more than 13,000 young people are diagnosed with type 1 diabetes. The CDC reports that type 2 diabetes appears to be a sizeable and growing problem among U.S. children and adolescents.

Type 1 vs. Type 2 Type 1 diabetes Type 2 diabetes
Diagnosed in children and young adults Typically diagnosed in adulthood Previously known as Juvenile Diabetes Also found in overweight children Insulin-dependent Non-insulin-dependent Body does not produce insulin Body fails to produce and properly use insulin There are two types of diabetes to consider. Type 1 diabetes, previously known as juvenile diabetes, is diagnosed in children and young adults. Type 1 diabetics are insulin-dependent, meaning that the body does not produce insulin. On the other hand, those considered to have type 2 diabetes are typically diagnosed in adulthood. However, type 2 diabetes is now being diagnosed in overweight children and teens. Type 2 diabetics are non-insulin dependent, which means the body fails to produce and properly use insulin. Remember, insulin is a hormone that is needed to convert glucose, starches and other food into energy that is needed to sustain life.

Diabetes: Warning Signs
Early diagnosis of diabetes requires recognizing the warning signs of diabetes. These signs include: urinating a lot, losing weight, lacking energy, and drinking a lot. If a child shows these signs, immediate medical attention is needed.

Blood Glucose Alterations
Complications of blood glucose alterations Hypoglycemia Hyperglycemia Ketosis Acidosis DKA (Hyperglycemia + Ketosis + Acidosis) A normal fasting blood glucose level is between 80 to 120 milligrams per deciliter. Glucose accumulates in the blood when the body fails to properly respond to its own insulin and/or does not make enough insulin. Complications of altered glucose levels include: hypoglycemia, hyperglycemia, ketosis, and acidosis. The combination of hyperglycemia, ketosis, and acidosis leads to DKA. Normal fasting blood glucose level mg/dL

Hypoglycemia Low blood glucose: treated when less than 60 mg/dL
Develops because the body doesn’t have enough glucose to burn energy Can happen suddenly Usually mild and can be treated quickly and easily by eating or drinking a small amount of glucose rich food The signs and symptoms include: Low blood glucose Hunger Headache Confusion, shakiness, dizziness Sweating Let’s take a closer look at each of the complications of diabetes. Hypoglycemia is the technical term for low blood glucose. It is treated when blood glucose level is less than 60 mg/dL. Hypoglycemia occurs when the body doesn’t have enough glucose to burn energy. Hypoglycemia can happen suddenly. It is usually mild and can be treated quickly and easily by eating or drinking a small amount of glucose rich food. The signs and symptoms include: low blood glucose, hunger, headache, confusion, shakiness, dizziness and sweating. If hypoglycemia is suspected, it is important to check the blood glucose concentration. If hypoglycemia is suspected, check the blood glucose concentration

Hyperglycemia High blood glucose: treated when greater than 200 mg/dL
Develops when the body has too much glucose in the blood Serious problem if not treated A major cause of many of the complications in children with diabetes The signs and symptoms include: High blood glucose High levels of glucose in the urine Frequent urination Increased thirst Hyperglycemia is another complication of diabetes. It is the technical term for high blood glucose. Hyperglycemia is treated when the blood glucose level is greater than 200 mg/dL. It is important to treat hyperglycemia as soon as it is detected. Failure to treat hyperglycemia can result in the condition called DKA. The signs and symptoms of hyperglycemia include: high blood glucose, high levels of glucose in the urine, frequent urination, and increased thirst. If hyperglycemia is suspected, it is important to check the blood glucose concentration. If hyperglycemia is suspected, check the blood glucose concentration

Hypoglycemia vs. Hyperglycemia
Low blood glucose (less than 60 mg/dL) High blood glucose (greater than 200 mg/dL) Signs and symptoms include: Shakiness Dizziness Sweating Hunger Headache Pale skin color Mental or behavior changes Lethargy Clumsy or jerky movements Seizure Difficulty concentrating Tingling sensations around the mouth Signs and symptoms include: Classic symptoms: Polyphagia (excessive hunger) Polyuria (excessive urine/urination) Polydipsia (excessive thirst) Other symptoms might include: Blurred vision Fatigue Weight loss Slow-healing cuts and sores Headaches Difficulty concentrating Vaginal and skin infections This slide provides an overview of the key differences between hypoglycemia and hyperglycemia. When providing treatment, it is important to know the child’s blood glucose level as well as the signs and symptoms. This will help in your assessment of the child and in determining your plan of care.

Ketosis Ketones Acidic substances that are made when the body breaks down fat for energy Ketosis Presence of excess ketones in the body Blood ketone concentration between 0.3 and 7.0 mmol/L Ketoacidosis Severe form of ketosis Reflects levels of 7.0 mmol/L or higher Lowers the pH to 7.3 or lower Ketosis is also a complication of diabetes. Ketones are acidic substances that are made when the body breaks down fat for energy. Ketosis is potentially a very serious condition that occurs when there are raised levels of ketones in the blood. Carbohydrates are normally broken down into glucose which is then converted into energy and transported to the body’s muscles and organs. However, if there is a lack of glucose, or if it is not possible for glucose to be utilized, the body will have to break down stored fat in order to convert it into energy. This is known as fat metabolism which results in a build up of ketones in the blood. As the body breaks down fat, the levels of ketones in the blood begin to rise. Ketosis indicates a blood ketone concentration between 0.3 and 7.0 mmol/L; while ketoacidosis reflects levels of 7.0 mmol/L or higher and is considered a severe form of ketosis. Ketoacidosis gets its name because high blood ketone levels lower the pH to 7.3 or lower.

Acidosis Increased acidity of the blood Acidemia is a pH below 7.35
Signs & Symptoms Deep, rapid breathing (known as Kussmaul’s respirations) confusion or lethargy abdominal pain Blood tests to diagnose metabolic acidosis may include: Arterial or venous blood gas Electrolytes: Na+ (sodium), K+ (potassium), Cl- (chloride) and HCO3- (bicarbonate) (total CO2 content) Another complication of diabetes is acidosis. Acidosis is a condition resulting from increased hydrogen ion concentration in the body and blood. The normal range of the arterial pH is between 7.35 to The body is designed to operate optimally with a pH of 7.40. The term acidemia describes the state of low blood pH, while acidosis is used to describe the processes leading to this state. Nevertheless, these terms are sometimes used interchangeably. Acidosis usually causes deep, rapid breathing, known as Kussmaul’s respirations. In addition, confusion or lethargy and abdominal pain may also be present. Blood tests, such as arterial or venous blood gas and electrolytes, are used to diagnose the presence and severity of acidosis.

DKA is a complex metabolic state of: hyperglycemia, ketosis, and acidosis
Symptoms include: Deep, rapid breathing Fruity breath odor Very dry mouth Nausea and vomiting Lethargy/drowsiness To review, DKA is a complex metabolic state of hyperglycemia, ketosis, and acidosis. As hyperglycemia, ketosis, and acidosis become more severe and life-threatening, immediate medical management is needed. Symptoms include: deep, rapid breathing or shortness of breath, breath that may have a fruity odor, nausea and vomiting , a very dry mouth, and lethargy or drowsiness. DKA may be the first symptom of previously undiagnosed diabetes. However, it may also occur in known diabetics due to a variety of causes, such as illness or infection or poor compliance with insulin therapy. DKA is diagnosed with blood and urine tests. It is distinguished from other rarer forms of ketoacidosis by the presence of high blood glucose levels. DKA is life-threatening and needs immediate treatment

The biochemical criteria for the diagnosis of DKA2,3
Classic Triad of DKA The biochemical criteria for the diagnosis of DKA2,3 Hyperglycemia - blood glucose greater than 200 mg/dL Ketosis - ketones present in blood and/or urine Acidosis - pH less than 7.3 and/or bicarbonate less than 15 mmol/L The biochemical criteria for the diagnosis of DKA is: hyperglycemia with a blood glucose greater than 200 mg/dL; the presence of ketones in the blood and/or urine; and a pH less than 7.3 and/or bicarbonate less than 15 mmol/L .

Classification of DKA DKA is generally categorized by the severity of the acidosis. MILD – Venous pH less than 7.3 and/or bicarbonate concentration less than 15 mmol/L MODERATE – Venous pH less than 7.2 and/or bicarbonate concentration less than 10 mmol/L SEVERE – Venous pH less than 7.1 and/or bicarbonate concentration less than 5 mmol/L DKA is generally categorized by the severity of the acidosis, using mild, moderate, and severe classifications.

Two Emergencies of Diabetes
Hypoglycemia Hyperglycemia Ketoacidosis/DKA Due to: Time of onset: Causes: Blood glucose: Ketones: Low blood glucose Fast – within seconds Too much insulin Too little food Too much exercise without food Missing or delayed meals/snacks Stress/overexcitement in young children Low (less than 60 mg/dL) None in urine or blood Presence of ketones Slow - within hours or days Insufficient insulin Missed insulin dose(s) Infections/illness Stress response High (greater than 200 mg/dL) Moderate/large in urine or blood For many years, we have considered two emergency problems in blood glucose control. The first is low blood glucose or hypoglycemia. Low blood glucose occurs quickly and must be treated promptly. Early treatment helps prevent a more severe reaction and possible hospitalization. Hypoglycemia occurs because the body doesn’t have enough glucose to burn for energy. Frequent causes may be too much insulin, too little food intake, too much exercise without food, missing or delayed meals or snacks, and stress or overexcitement in young children. A low blood glucose is treated when it is less than 60 mg/dL. In hypoglycemia, no ketones are found in the blood or urine. The other emergency is the build-up of ketones in the blood and urine, which can develop into ketoacidosis. Large urine or blood ketones are usually present for at least four hours before the blood acidity is increased. Ketoacidosis is a very dangerous condition that, if untreated, can lead to coma and eventual death. It is the cause of 85% of hospitalizations of children with known diabetes. Causes include: insufficient insulin, missed insulin dose, infections or illness, and stress response. Ketoacidosis is characterized by blood glucose levels greater than 200 mg/dL and moderate to large ketones in the blood and urine.

New Emerging Third Emergency: Hyperglycemic Hyperosmolar Syndrome (HHS)
Similar symptoms to DKA Elevated blood glucose Dehydration Altered mental status HHS4,5 Severe dehydration Little or no ketone accumulation Elevated blood glucose levels greater than 600 mg/dL, frequently exceeds 1000 mg/dL Elevated serum osmolality (over 320 mOsm/kg H2O) Children with type 2 diabetes may be at greatest risk Occurs infrequently in children, so data regarding the optimal approach to treatment are lacking An emerging issue in pediatrics is a third condition related to altered glucose and fat metabolism. Hyperglycemic Hyperosmolar Syndrome, known as HHS, has been viewed as a condition separate from DKA. It may be more appropriate to view HHS as one extreme in the various presentations of altered glucose and fat metabolism in children with diabetes. HHS has a similar presentation to DKA: elevated blood glucose, dehydration, and an altered mental status. In addition, the combination of elevated glucose and dehydration leads to elevated serum osmolality or a hyperosmolar state. Severe dehydration is the predominate feature. HHS has little or no ketone accumulation, but does have blood glucose levels greater than 600 mg/dL and frequently exceed 1000 mg/dL. Children with type 2 diabetes may be at greatest risk for HHS. Because HHS occurs infrequently in children, data regarding the optimal approach to treatment is lacking. For more information on HHS, consult the ADA guidelines.

Beta-hydroxybutyrate
Classifications of DKA Diagnostic Criteria for Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State Mild DKA Moderate DKA Severe DKA HHS Blood glucose >200 mg/dL >600 mg/dL Venous pH < 7.3 < 7.2 < 7.1 > 7.3 Serum bicarbonate < 15 mEq/L < 10 mEq/L < 5 mEq/L > 15 mEq/L Urine ketones Positive Small or none Blood ketones Beta-hydroxybutyrate High Normal or elevated Serum osmolality Variable > 320 mOsm/kg H2O Alteration in mental status Alert Alert/drowsy Stupor/coma It is important to recognize that an overlap between the characteristic features of DKA and HHS may occur. Therapy must be appropriately modified to address the pathophysiology and unique biochemical disturbances of each individual child.

Pathophysiology of DKA
The pathophysiology of DKA in children is summarized in this diagram. The interacting factors are: insulin deficiency as the primary event which is augmented by stress, infection or insufficient insulin intake, and the excess of high counter-regulatory hormone concentrations. This combination results in an increased glucose production by the liver and kidney. This is known as glycogenolysis (the breakdown of glycogen) and gluconeogenesis (the synthesis of glucose). If this cycle is not interrupted with insulin, fluids and electrolyte therapy, severe dehydration and metabolic acidosis will occur. Wolfsdorf J, Glaser N, Sperling MA; American Diabetes Association. Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement from the American Diabetes Association. Diabetes Care. 2006;29(5): Reprinted with permission from The American Diabetes Association.

Insulin deficiency Excess counter-regulator hormones hyperglycemia glucosuria osmotic diuresis dehydration glucagon, cortisol, catecholamines and growth hormone ketogenesis Let’s review the concepts from the previous slide. Low serum insulin concentrations lead to diminished peripheral glucose uptake and increased hepatic glucose output resulting in hyperglycemia. When the rise in serum glucose concentration exceeds the renal tubular threshold for glucose reabsorption, urine glucose levels rise. Elevated urine glucose, which is glucosuria, leads to osmotic diuresis. Further declines in insulin secretion eventually result in a relative excess of counter-regulatory hormones in relation to insulin. This imbalance between insulin and counter-regulatory hormones stimulates ketogenesis. Continued ketone production eventually results in acidosis. acidosis

Dehydration Depletion of electrolytes sodium, potassium, chloride, phosphate and magnesium osmotic diuresis + acidosis DKA As the ability to compensate for the osmotic diuresis decreases, dehydration results. As dehydration progresses, tissue perfusion is eventually diminished, resulting in production of lactic acid and worsening of the acidosis. Severe dehydration leads to impaired renal function and diminished capacity for clearance of glucose and ketones, increasing both hyperglycemia and acidosis. Depletion of electrolytes occurs as a result of osmotic diuresis and acidosis. The combination of acidosis and osmotic diuresis leads to the classic symptoms of DKA.

ASSESSMENT Return to Table of Contents
Now, let’s review the elements that make up an appropriate assessment. Early recognition of DKA is achieved through obtaining a careful history and performing a thorough physical examination. Return to Table of Contents

Clinical Presentation
Nausea, vomiting Polyuria Polydipsia Weight loss Fruity breath odor Abdominal pain Lethargy/drowsiness Confusion Coma Children in DKA generally present with nausea and vomiting. In children who have no previous diagnosis of diabetes mellitus, a preceding history of polyuria, polydipsia, and weight loss usually can be elicited. With significant ketosis, children may have a fruity breath odor. Acidosis and ketosis can cause an ileus that can lead to abdominal pain severe enough to raise concern for an acute abdomen. As the DKA becomes more severe, lethargy develops due to the acidosis and hyperosmolarity. In severe DKA, the child may present with an altered mental status or coma.

Thorough History is Imperative!
New diabetic Recent history of Polyuria Polydipsia Polyphagia Weight loss Past medical history Family history of diabetes History/duration of symptoms Headache Blurry vision Nausea/vomiting/ abdominal pain Difficulty in breathing Changes in behavior Precipitating factors Concurrent illness or infection Known diabetic History of diabetes and duration Last meal/carbohydrate intake Current and routine blood glucose levels Standard insulin regimen Last insulin dose Type of insulin and route Past hospitalization history Duration of symptoms Nausea/vomiting/abdominal pain Precipitating factors Physical exertion Change in eating habits/diets Stress Missed insulin dose Illness Regardless if the child is a new diabetic or a known diabetic, a thorough history is imperative in any assessment. It is important to obtain a complete history of the child presenting in DKA for the first time. Typically, a recent history includes polyuria, polydipsia, polyphagia, and weight loss. Obtain a past medical history and, importantly, any family history of diabetes. Review the history and duration of symptoms such as: headache, blurry vision, nausea, vomiting, abdominal pain, difficulty in breathing, and any changes in behavior. Identify any precipitating factors such as concurrent illness or infection. In a known diabetic, it is important to review their disease history. Obtain information on timing of carbohydrate intake, and current and routine blood glucose levels. Review their insulin regimen such as: last insulin dose, type and route. Review past hospitalization history and duration of symptoms. Identify any precipitating factors such as physical exertion, change in eating habits or diet, stress, missed insulin doses, and recent illness. For a child with known diabetes, the most common cause for DKA is omission of insulin doses. Such action can result from failure of an insulin pump, prolonged disconnection from an insulin pump without appropriate monitoring, and improper discontinuation of insulin during an illness associated with poor oral intake. For an older child who has the responsibility for managing his or her diabetes without adult oversight, DKA most often is caused by the child forgetting to administer insulin doses.

Physical Assessment Assess for dehydration Assess for acidosis
Vital signs, mucous membranes, capillary refill, skin (color, temperature and turgor) Assess for acidosis Fruity breath odor Deep, rapid breathing → Kussmaul’s respirations Assess mental status → watch for cerebral edema! AVPU PGCS Assess for signs/symptoms of possible infection The physical examination can provide supportive evidence for diagnosis and can point to precipitating factors. The physical assessment should include assessing degree of dehydration by looking at vital signs, mucous membranes, capillary refill and skin color, temperature and turgor. Assess for acidosis, fruity breath odor, and Kussmaul’s respirations. Assess mental status and watch for signs of cerebral edema. The physical assessment should also search for signs of possible infection. While isolated leukocytosis during DKA is not a reliable indicator of infection, infection can be a precipitant of DKA. Therefore, careful evaluation and early treatment of any infection is important.

Assessment Resources Systematic Assessment
Pediatric Assessment Triangle (PAT) Initial Assessment (ABCDE) Focused Physical Examination (FGHI) Triage (E-U-N) Emergency Severity Index (ESI) AVPU Scale Pediatric Glasgow Coma Scale (PGCS) There are many assessment resources to assist in gathering essential information. Keep these in mind as you proceed with providing treatment. The goal of the primary assessment is to rapidly identify and treat life-threatening emergencies. Detailed information regarding these assessment resources can be found in Appendix A. For more information, click on these links or proceed to Appendix A

Systolic Blood Pressure
Normal Values Pediatric Vital Signs By Age Age Respiratory Rate (breaths/minute) Heart Rate (beats/minute) Systolic Blood Pressure (mmHg) Neonate (0-30 days) 50 – 90 Infant (1-12 mo) Toddler (1-3 yr) Preschooler (3-5 yr) School age (5-12 yr) Adolescent (12 yr/up) This graph shows normal values for pediatric respiratory rates, pulse rates, and blood pressure. Note that children with certain chronic conditions may have baseline vital signs that fall outside the normal range for their age. Also note that since children’s vital signs vary by age, subtle abnormalities can be easily overlooked. Source: Illinois EMSC School Nurse Emergency Care Course Fourth Edition, 2010

Initial Assessment Assess Airway, Breathing, and Circulation
Perform a clinical evaluation Obtain vital signs and weight (kg) Assess clinical severity of dehydration Assess neurological status AVPU PGCS Apply cardiac monitor DKA is a medical emergency. Resuscitation should follow the “ABC” process - airway, breathing and circulation. Perform a clinical evaluation to rapidly identify and treat life-threatening emergencies. Carefully look for evidence of infection. Obtain vital signs and weigh the patient, in kilograms. This is the weight that should be used for calculations and not a weight from a previous office visit or hospital record. If body surface area is needed for fluid therapy calculations, measure the child’s height or length to determine surface area. Also assess the clinical severity of dehydration. Clinical assessment of dehydration should be based on a combination of physical signs. The three most useful individual signs are: prolonged capillary refill time, abnormal skin turgor and tachypnea. Other useful signs in assessing dehydration include: dry mucus membranes, sunken eyes, absent tears, weak pulses, and cool extremities. In addition, as part of your initial assessment, assess the neurological status utilizing assessment tools such as AVPU or the Pediatric Glasgow Coma Scale. Lastly, provide cardiac monitoring.

Laboratory Evaluation
Initial Labs Blood glucose Urine ketones Venous blood gas Basic blood chemistry Electrolytes BUN, creatinine Magnesium, calcium, phosphorus Additional labs CBC Osmolality Serum beta-hydroxybutyrate (β-OH) Hemoglobin A1c (HgbA1c) Pancreatic antibodies Additional testing as indicated CXR, non-contrast Head CT, Cultures (blood, urine, throat) Making a firm diagnosis of DKA in the pre-hospital setting is difficult given the lack of lab testing abilities. However, an abnormal blood glucose value in combination with other clinical findings such as ketotic breath and Kussmaul’s respirations, may suggest the diagnosis. In the emergency department, the initial laboratory evaluation should include blood glucose, urine ketones, venous blood gas (or arterial blood gas in critically ill children) and other basic blood chemistry. These labs are critically important. Secondary labs would include a CBC, blood osmolality, Beta-Hydroxybutyrate, Hemoglobin A1c and pancreatic antibodies. Additional testing may be indicated such as a chest x-ray, a CT of the head and cultures of the blood, urine, and throat. Note: when interpreting the lab results, an increased white blood cell count in response to stress is characteristic of DKA and is not necessarily a sign of infection.

Blood Glucose Testing A blood glucose test measures the amount of glucose in the blood Blood glucose tests are done to screen and monitor treatment Normal glucose range is between 80 and 120 mg/dL A blood glucose test measures the amount of glucose in the blood and is done to screen and monitor treatment. As mentioned previously, the normal glucose range is between 80 and 120 mg/dL.

Ketone Testing Blood Ketone Reading Indications Urine Ketone Testing
Above 1.5 mmol/L Readings above 1.5 mmol/L in the presence of hyperglycemia indicate the child may be at risk for developing diabetic ketoacidosis (DKA). 0.6 to 1.5 mmol/L Readings between 0.6 and 1.5 mmol/L may indicate the development of a problem that may require medical assistance. Below 0.6 mmol/L Readings below 0.6 mmol/L are in the normal range. There are two ways to test for ketones: urine testing and blood testing. In DKA, it is highly recommended to test blood ketone levels rather than urine. Ketones in the blood can be detected well before ketones in the urine. Ketone test strips are used to determine the presence of ketones in the urine. An outdated or expired test strip may yield a false-positive reading. Urine Ketone Testing Out-dated or expired test strips may cause a false-positive reading.

Blood Gases VBG is sufficient unless altered level of consciousness
ABG arterial blood sample or VBG venous blood sample are both adequate to determine blood pH. VBG is sufficient unless altered level of consciousness Remember: arterial puncture is a painful procedure; consider using topical anesthetic as a pain reducing therapy An ABG provides a snapshot of the blood’s pH + PO2 + PCO2 = HCO3 pH – indicates if acidotic or alkalemic PO2 – the amount of oxygen dissolved in the blood PCO2 – the amount of carbon dioxide dissolved in the blood HCO3 – the amount of bicarbonate in the blood Metabolic acidosis is defined as a low pH and decreased HCO3 Metabolic alkalosis is defined as a high pH and increased HCO3 Blood gas tests are indicated in the presence of an oxygen, carbon dioxide or pH imbalance. They can be performed on either an arterial or venous blood sample. A venous blood gas is sufficient unless altered level of consciousness is present. When conducting an arterial puncture, remember that it can be a painful procedure, so consider using a topical anesthetic as a pain reducing therapy. Blood gases are a snapshot of the blood’s pH, the amount of oxygen dissolved in the blood and the amount of carbon dioxide dissolved in the blood. From these results, the amount of bicarbonate can be calculated. Metabolic acidosis is defined as a lower pH and decreased bicarbonate, and is seen in severe cases of DKA. Metabolic alkalosis is defined by an elevated pH and increased bicarbonate, and is commonly caused by hypokalemia.

MANAGEMENT Return to Table of Contents
Now, we will discuss appropriate ways to manage children who present with Hyperglycemia and DKA. Return to Table of Contents

Not All Children Are The Same!
Be prepared to make adjustments frequently! Goals Of Therapy Correct dehydration Correct acidosis and reverse ketosis Restore normal blood glucose levels Avoid complications of therapy Not all children are the same! Therefore, the information in this section should be considered a guide to your management and may need to be tailored based on how each individual child presents. Be prepared to make adjustments frequently. The goals of therapy are to: correct dehydration, correct acidosis and reverse ketosis, restore normal blood glucose levels, and avoid complications of therapy. It’s important to note that these are guidelines and cannot replace careful clinical observation and judgment in treating this potentially very serious condition.

Treatment Overview Follow established guidelines
Consider need for consultation and transfer to higher level of care Recognize and prevent serious complications such as cerebral edema Maintain strict NPO IV fluids Phase I Initial volume expansion Phase II Replacement of fluid deficit Maintenance fluids Insulin administration (begins after the initial fluid resuscitation) Continuous IV insulin infusion Subcutaneous/Intramuscular Electrolyte replacement Reassessment and ongoing monitoring When treating children with DKA, it is important to ensure basic principles of DKA treatment. Each institution should have a pediatric-specific DKA protocol based on established guidelines such as the ADA, ESPE, and LWPES guidelines. Consider the need to consult with a Pediatric Endocrinologist or Intensivist and, if necessary, initiate the process of transfer to a higher level of care. Recognize and prevent complications such as cerebral edema. Maintain strict NPO to avoid aspiration. Administer IV fluids in two phases. During phase one, fluids are administered over the first hour and involve initial volume expansion. Phase two includes ongoing replacement of fluid deficits and maintenance fluids. Administration of insulin is thru continuous IV insulin infusion. In circumstances where IV insulin infusion is not possible, hourly subcutaneous or intramuscular insulin injections may be effective. Along with fluid replacement and insulin administration, electrolyte replacement should be initiated. Most importantly, treatment guidelines should include continuous reassessment and ongoing monitoring.

Management of Pediatric Patients with DKA
Complete initial evaluation Initial hour - start IV fluids IV Fluids Insulin Potassium Dextrose The following slides will discuss, in detail, treatment guidelines for fluids, insulin, potassium, and dextrose administration. These guidelines are adapted from the American Diabetes Association. Remember these guidelines and treatment plans may need to be modified according to each child’s needs. Management of pediatric DKA begins with a complete initial evaluation and the start of the initial hour of IV fluids. Advance to slide 49 Advance to slide 51 Advance to slide 54 Advance to slide 61 Adapted from: Kitabchi AE, Umpierrez GE, Murphy MB, et al; American Diabetes Association. Hyperglycemic crises in diabetes. Diabetes Care. 2004;27(Suppl. 1):S94-S102

IV Fluid Administration
IV Fluids The goal of the first hour of treatment fluid resuscitation confirmation of DKA by laboratory studies The goals of the second and succeeding hours slow correction of hyperglycemia, metabolic acidosis and ketosis continued volume replacement This usually requires several hours and meticulous attention to the patient's response to therapy Determine hydration status Mild to moderate dehydration Hypovolemic shock Treatment of DKA begins with intravenous fluid replacement. Administer normal saline at 10 mL/kg over 1 hour. The goal of the first hour of treatment is fluid resuscitation and confirmation of DKA by laboratory studies. Rarely will a fluid bolus of greater than 20 mL/kg be required to maintain perfusion. Large fluid boluses are potentially dangerous and should be avoided, unless the child is in shock. In cases of hypovolemic shock, rapidly restore circulatory volume with isotonic saline in 20 mL/kg boluses infused as quickly as possible. The goals of the second and succeeding hours are slow correction of hyperglycemia, metabolic acidosis and ketosis, in addition to continued volume replacement. This usually requires several hours and meticulous attention to the child’s response to therapy. Administer 0.9% NS 10 mL/kg/hr over initial hour Administer 0.9% NS 20 mL/kg bolus infused as quickly as possible Replace fluid deficit evenly over 48hr with 0.45 – 0.9% NS Adapted from: Kitabchi AE, Umpierrez GE, Murphy MB, et al; American Diabetes Association. Hyperglycemic crises in diabetes. Diabetes Care. 2004;27(Suppl. 1):S94-S102

ALL PATIENTS WITH DKA REQUIRE SUPPLEMENTAL FLUIDS
IV Fluid Key Points Start IV fluids: ml/kg of 0.9%NS over the first hour In a severely dehydrated patient, this may need to be repeated Fluids should not exceed 50 ml/kg over first 4 hours of therapy Clinical assessment of dehydration to determine fluid volume Children with DKA have a fluid deficit in the range of 5-10% Mild DKA 3-4% dehydration Moderate DKA 5-7% dehydration Severe DKA 10% dehydration Shock is rare in pediatric DKA Replace fluid deficit evenly over 48 hours REMINDER: Serum sodium decreases by 1.6mEq/L for every mg/dl increase in serum glucose concentration above 100mg/dl, therefore no electrolyte correction is needed Let’s review IV fluid key points. All children with DKA require supplemental fluids. Intravenous fluid replacement is initiated as soon as possible. Initial treatment should be directed at restoring perfusion. Start IV fluids of mL/kg of 0.9% NS in the initial hour. In a severely dehydrated child, the fluid bolus may need to be repeated. In critically ill children, for whom there is concern over impending cardiovascular collapse, fluids should be administered rapidly. Fluid replacement should not exceed 50 mL/kg over the first 4 hours of therapy. Children with DKA have a fluid deficit in the range of 5 – 10 percent. After the first hour, the remaining fluid deficit should be replaced evenly over a 48-hour period. As a reminder, serum sodium decreases by 1.6mEq/L for every 100-mg/dl increase in serum glucose concentration above 100mg/dl, therefore no electrolyte correction is needed. ALL PATIENTS WITH DKA REQUIRE SUPPLEMENTAL FLUIDS

Insulin Administration
Insulin treatment is begun after the initial fluid resuscitation Insulin therapy Turns off the production of ketones Decreases blood glucose Low-dose insulin infusion Decreases risk of hypoglycemia or hypokalemia Goal is to decrease blood glucose by 100mg/dL/hour INSULIN IV insulin infusion regular insulin 0.1 units/kg/hr Continue until acidosis clears (pH >7.30, HC03 >15 mEq/L) Insulin treatment is begun after the initial fluid resuscitation. Insulin therapy is needed to turn off the production of ketones (a cause of acidosis). Low-dose insulin infusion decreases the risk of hypoglycemia or hypokalemia. The goal is to lower blood glucose no faster than 100 mg/dL/hour. Do not reduce or discontinue the insulin infusion based solely upon the blood glucose. The insulin infusion should be continued until the pH is greater than 7.30 and/or the bicarbonate is greater than 15, and the serum ketones have cleared. Keep in mind that you may need to begin a dextrose infusion while continuing the insulin infusion. Do not reduce or discontinue the insulin infusion based solely upon the blood glucose Decrease to 0.05 units/kg/hr until SQ insulin initiated The insulin infusion should be continued until the ph >7.30 and/or the HCO3 >15 mEq/L and the serum ketones have cleared Adapted from: Kitabchi AE, Umpierrez GE, Murphy MB, et al; American Diabetes Association. Hyperglycemic crises in diabetes. Diabetes Care. 2004;27(Suppl. 1):S94-S102

Do not give insulin as a bolus
Insulin Key Points Prior to insulin administration, reassess vital signs, blood glucose level and neurological status Insulin is administered as a continuous intravenous infusion of regular insulin at a rate of 0.1 units/kg per hour (prepared by pharmacy) Insulin is a “High-Alert” medication, therefore two nurses should verify the insulin order, dose, and volume prior to administration IV tubing should be primed with the insulin solution before administration Do not give insulin as a bolus Let’s review some insulin key points. Insulin treatment is begun after the initial fluid resuscitation; that is, at the beginning of the second hour of therapy. Starting insulin treatment at the same time as fluid resuscitation increases the risks of severe hypokalemia and of rapidly and excessively decreasing the serum osmolarity. Prior to insulin administration, reassess vital signs, blood glucose level, and neurological status. Insulin is administered as a continuous intravenous infusion of regular insulin at a rate of 0.1 units/kg/hour. An insulin drip should be prepared by the pharmacy and IV insulin boluses are always contraindicated. Insulin is a “High-Alert” medication, therefore two nurses should verify the insulin order, dose, and volume prior to administration. IV tubing should be primed with the insulin solution before administration. This will saturate binding sites on the tubing. At the time of insulin infusion, make sure any indwelling insulin pump has been disconnected and/or stopped. At the time of insulin infusion, make sure any indwelling insulin pump has been disconnected and/or stopped

Insulin Key Points (cont.)
The dose of insulin should remain at 0.1 units/kg/hour until the acidosis resolves (pH 7.3 and/or bicarbonate >15 mEq/L) Do not decrease rate or stop the insulin administration based solely on glucose values Once blood glucose reaches 250 mg/dL, maintain insulin and begin dextrose infusion If the acidosis is not improving, consult with a Pediatric Endocrinologist or Intensivist since the insulin dose may need to be increased to 0.15 or 0.20 units/kg/hour If IV infusion is not possible, insulin injected intramuscularly or subcutaneously every 1 or 2 hours can be effective The dose of insulin should remain at 0.1 units/kg/ hour until the acidosis resolves (when the pH is 7.3 and bicarbonate is greater than 15 mEq/L). Do not decrease the rate or stop the insulin administration based solely on glucose values. However, once the blood glucose reaches 250 mg/dL, begin a dextrose infusion. Resolution of the acidosis in DKA takes longer than the time to achieve a normal blood glucose concentration. Avoid decreasing the rate of insulin administration based on glucose values because this practice delays resolution of the acidosis. If the acidosis is not improving, consult with a Pediatric Endocrinologist or Intensivist. The insulin dose may need to be increased to 0.15 or 0.20 units/kg/hour. Though not recommended, if intravenous infusion is not possible, insulin injected intramuscularly or subcutaneously every one or two hours can be effective.

Potassium Administration: General Guidelines
Start replacing potassium after initial fluid resuscitation and concurrent with starting insulin therapy MONITOR CLOSELY!!! In general, in patients with DKA, there is a significant potassium deficit that must be replaced Potassium replacement should continue throughout IV fluid therapy The maximum recommended rate of IV potassium replacement is institution specific Consult with your Pharmacist before administering potassium In children with DKA, expect potassium deficits of between 3 and 6 mmol/kg, regardless of the initial serum potassium which may be normal. Therefore, potassium replacement therapy is required. Unless hypokalemic, start replacing potassium after initial fluid resuscitation and concurrent with starting insulin therapy. Both correction of acidosis and supplemental insulin cause intracellular shift of potassium into cells resulting in a fall in serum potassium. Potassium replacement should follow your institution’s protocol, but in general, replace no faster than 10 mEq/hour thru a peripheral IV or 20 mEq/hour through a central line.

Potassium Administration (cont.)
When initial serum potassium is <2.5 mmol/L (hypokalemia) Administer mEq/kg of potassium chloride in IV Administer at rates specified by your institutional protocol or utilize a standard pediatric reference Start potassium replacement early, even before starting insulin therapy Over the next few slides, we will discuss potassium administration based on specific serum potassium levels. The normal serum potassium level ranges between 3.5 to 5.0 mmol/L. If the initial serum potassium level is less than 2.5 mmol/L, start potassium replacement in the first hour, even before starting insulin therapy. Remember to refer your institution’s protocol for administration rates.

When initial serum potassium is mmol/L Administer potassium 40 mEq/L in IV solution until serum potassium > 3.5 mmol/L Monitor serum potassium hourly Administer potassium 30 – 40 mEq/L in IV solution to maintain serum potassium at 3.5 – 5.0 mmol/L When the initial serum potassium level is between 2.5 and 3.5 mmol/L, administer potassium 40 mEq/L in IV solution until the serum potassium level is greater than 3.5 mmol/L. Remember to monitor the serum potassium hourly. Then, to maintain the serum potassium between 3.5 and 5.0 mmol/L, administer potassium 30 to 40 mEq/L in IV solution.

When initial serum potassium is mmol/L Administer potassium 30 – 40 mEq/L in IV solution to maintain serum potassium at 3.5 – 5.0 mmol/L Monitor serum potassium hourly Normal serum potassium level ranges between 3.5 to 5.0 mmol/L. When initial serum potassium reaches this level, the goal is to maintain by administering potassium 30 to 40 mEq/L in IV solution. Remember to continue to monitor the serum potassium every hour. Normal serum potassium level ranges between 3.5 to 5.0 mmol/L

When initial serum potassium is > 5.0 mmol/L (hyperkalemia) Do not give IV potassium in initial fluids Monitor serum potassium hourly until < 5.0 mmol/L Then begin IV fluids with potassium to maintain serum potassium at 3.5 – 5.0 mmol/L If the initial serum potassium is greater than 5.0 mmol/L, the child is hyperkalemic. Do not give IV potassium in the initial fluids. Monitor the serum potassium hourly until the level is less than 5.0 mmol/L. Then, potassium can be added to the IV fluids to maintain a serum potassium range of between 3.5 to 5.0 mmol/L. It is important to defer potassium replacement therapy in hyperkalemia until the child has voided. Defer potassium replacement therapy until child has voided

EKG Hypokalemia Hyperkalemia
Normal serum potassium level ranges between 3.5 to 5.0 mmol/L Hypokalemia Flattening T wave, widening of the QT interval, and appearance of U waves If immediate serum potassium measurements are unavailable, an EKG may help to determine whether the child has hypokalemia or hyperkalemia. Flattening of the T wave, widening of the QT interval and the appearance of U waves indicate hypokalemia. Tall, peaked, symmetrical, T waves and shortening of the QT interval are signs of hyperkalemia. Hyperkalemia Tall, peaked symmetrical, T waves and shortening of QT intervals

Potassium Key Points Potassium loss in DKA due to:
vomiting osmotic diuresis Potassium levels should be maintained at 3.5 – 5.0 mmol/L Abnormal or critical values require hourly potassium checks Consult with a Pediatric Endocrinologist or Intensivist about abnormal values Suggested potassium replacement can be administered as follows: Potassium phosphate with potassium chloride Potassium phosphate with potassium acetate Let’s review some potassium key points. Potassium is lost from the body from vomiting and as a consequence of osmotic diuresis. Potassium levels should be maintained between 3.5 and 5.0 mmol/L. Abnormal or critical potassium levels should be monitored hourly in consultation with a Pediatric Endocrinologist or Intensivist . Potassium replacement can be administered as a combination of either potassium phosphate with potassium chloride or potassium phosphate with potassium acetate. A suggested administration would be potassium phosphate 20 mEq with potassium acetate 20 mEq. Suggested administration: Potassium Phosphate 20mEq + Potassium Acetate 20mEq (unless hypophosphatemia develops)

Dextrose Administration
Maintain glucose between 150 to 250 mg/dL to prevent hypoglycemia Check glucose hourly until stable Check electrolytes every 2-4 hrs until stable Add to IV fluids when the blood glucose concentration reaches 250 mg/dL Change to 5% dextrose with 0.45 NaCl at a rate to complete rehydration in 48 hr To prevent hypoglycemia during insulin therapy, dextrose should be added to the intravenous fluids when the blood glucose concentration reaches 250 mg/dL. Begin with 5% dextrose in 0.45% NaCl at a rate to complete rehydration in 48 hours, and to maintain glucose between 150 to 250 mg/dL. Tertiary care centers that may be interested in an alternate method for dextrose administration called the “two-bag system” can refer to Appendix B for more information on this system. Typically, blood glucose concentrations decrease to the normal range before ketosis and acidosis have resolved. When this occurs, it is preferable to continue insulin at the same dosage and increase the concentration of dextrose in the intravenous fluids to prevent hypoglycemia. Check glucose hourly and electrolytes every two to four hours until stable. After resolution of DKA, initiate subcutaneous insulin at 0.5 – 1.0 units/kg/day and/or according to insulin guidelines per the hospital policy or physician direction. Check glucose hourly and electrolytes every 2-4 hr until stable After resolution of DKA, initiate SQ insulin 0.5 – 1.0 units/kg/day (or according to insulin dosing guidelines per institution or physician policy) Adapted from: Kitabchi AE, Umpierrez GE, Murphy MB, et al; American Diabetes Association. Hyperglycemic crises in diabetes. Diabetes Care. 2004;27(Suppl. 1):S94-S102

Bicarbonate Bicarbonate therapy is generally contraindicated in Pediatric DKA due to increased risk of cerebral edema.6,7,8,9 Consult with a Pediatric Endocrinologist and/or Intensivist prior to initiating bicarbonate! Bicarbonate therapy should only be considered in cases of: Severe acidemia Life-threatening hyperkalemia10 Large bicarbonate losses are typical in DKA. The administration of insulin stops further ketoacid production and allows excess ketoacids to be metabolized, which generates bicarbonate. Also, treatment of hypovolemia will improve tissue perfusion and renal function, thus, increasing the excretion of organic acids. For these reasons, administration of bicarbonate is generally contraindicated. Treatment with bicarbonate therapy can cause hypokalemia as well as increased osmolality from the increased sodium being administered. Therefore, it is imperative to consult with a Pediatric Endocrinologist and or Intensivist prior to administering any bicarbonate. Presently, the indications for bicarbonate therapy in DKA are unclear, and under most circumstances, there are actually compelling arguments against it. Some studies have shown no clinical benefit from administration of bicarbonate and even suggest that the use of bicarbonate in children with DKA has been associated with an increased risk of cerebral edema. Bicarbonate therapy should be considered only in cases of severe acidemia, in whom decreased cardiac contractility and peripheral vasodilatation can further impair tissue perfusion and secondly, in those children with life-threatening hyperkalemia.

Children presenting with DKA must be monitored closely
Monitoring Children presenting with DKA must be monitored closely Hourly assessments: Vital signs pulse, respiratory rate, B/P, oxygen saturation, temperature, and pain level (as applicable) Neurological status Accurate fluid intake/output Point-of-care-testing blood glucose level Potassium level A flow sheet is invaluable for monitoring and documentation Successful management of DKA requires meticulous monitoring of the child’s clinical and biochemical response to treatment. Timely adjustments in treatment can be made when indicated by the child’s clinical and/or laboratory data. When monitoring and documenting the progression of DKA management, a flow sheet is invaluable. In addition to blood glucose monitoring, hourly assessments should include: clinical observations, intravenous and oral medications, fluid intake and output, laboratory results, and vital signs, such as heart rate, respiratory rate, blood pressure, oxygen saturation, temperature and pain level, as applicable. Additional assessments should include neurological observations, including a Pediatric Glasgow Coma Score. Neurological changes could indicate development of cerebral edema. Documentation on a flow chart is typically done hourly or more frequently as indicated. In the presence of poor peripheral circulation and acidosis, point-of-care-testing may need to be cross checked against laboratory venous glucose. The treating physician should be notified immediately of any critical lab values or change in mental status. Notify the treating physician immediately with any critical lab values or change in mental status.

Monitoring (cont.) Every 2 hours: Continuous cardiac monitoring
Urine ketones Serum β-OH Labs (repeated every 2– 4 hours or more frequently, as indicated in more severe cases) serum glucose, electrolytes, BUN, calcium, magnesium, phosphorus, hematocrit, and blood gases Continuous cardiac monitoring Amount of administered insulin Testing should continue with evaluation of urine ketones and serum BOH every two hours until cleared. Additional laboratory tests as indicated should be repeated every two to four hours. Continuous cardiac monitoring should be done to assess for arrhythmias and for the presence of abnormal T waves, which would indicate hyperkalemia or hypokalemia. Insulin administration should be monitored closely and documented hourly, or more frequently as indicated. All insulin rate and dose changes should be doubled checked by two nurses and documented on the flow sheet. All insulin rate/dose changes should be doubled checked by two nurses and documented on the flow sheet.

Additional Measures Administer oxygen
Insert additional peripheral intravenous catheter for repetitive blood sampling Children with altered mental status or consciousness, consider: Secure the airway Nasogastric suction Bladder catheterization Administer oxygen to those children with severe circulatory impairment or shock. In the unconscious child, ensure a secure airway. To prevent aspiration, nasogastric suction may be necessary. Consider additional intravenous access for convenient and painless repetitive blood sampling. Although monitoring output is important, catheterization of the bladder is usually not necessary.

Introduction of Oral Fluids
Oral fluids should be introduced: only when substantial clinical improvement has occurred – note that mild acidosis/ketosis may still be present When oral fluid is tolerated, IV fluid should be reduced If continuing fluids for hydration, remove dextrose from the IV. Consider introducing oral fluids only when substantial clinical improvement has occurred. Be aware that mild acidosis and ketosis may still be present. IV fluids should be reduced when oral fluid is tolerated. Once the child begins eating, if IV hydration is still needed, it should no longer include dextrose. Note that ketoacidosis is resolved when blood glucose is less than 200 mg/dL, serum bicarbonate is greater than or equal to 15 mEq/L and/or venous pH is greater than 7.3, and oral intake is tolerated. Ketoacidosis is resolved when: blood glucose is < 200 mg/dL serum bicarbonate is ≥ 15 mEq/L and/or venous pH > 7.3 oral intake is tolerated

Transition to Subcutaneous Insulin Injections
Transition to subcutaneous insulin when: Ketoacidosis has resolved, and Oral intake is tolerated Initiate subcutaneous insulin unit/kg/day Before a mealtime Before stopping the insulin infusion Do not stop the insulin infusion before the first injection Transition the child to subcutaneous insulin injections when ketoacidosis has resolved, and oral intake is tolerated. Initiate subcutaneous insulin at unit/kg/day. The most convenient time to change to the first subcutaneous insulin injection is just before a mealtime. To avoid rebound hyperglycemia, do not stop the insulin infusion before the first injection. This will allow sufficient time for the insulin to be absorbed. The dose and type of subcutaneous insulin given should be based on hospital or physician guidelines. After transitioning to subcutaneous insulin, frequent blood glucose monitoring is required to avoid marked hyperglycemia and hypoglycemia. The dose and type of subcutaneous insulin given should be based on hospital or physician guidelines After transitioning to subcutaneous insulin, frequent blood glucose monitoring is required to avoid marked hyperglycemia and hypoglycemia

High-Risk Patients New-onset diabetes
Severe DKA (including long duration of symptoms) Compromised circulation Depressed level of consciousness Increased risk for cerebral edema children less than 5 years of age Any child who might benefit from consultation with pediatric critical care specialists and transfer to specialized pediatric critical care centers Once DKA is suspected, early consultation with a Pediatric Endocrinologist or Intensivist regarding management and treatment is essential. Children who should be considered for admission to a PICU or transfer to a higher level of care are those with: new-onset diabetes, signs of severe DKA including long duration of symptoms, compromised circulation, depressed level of consciousness, increased risk for cerebral edema, particularly children less than five years of age, and any child who may benefit from consultation with pediatric critical care specialists and transfer to a specialized pediatric critical care center. Consult with a Pediatric Endocrinologist/Intensivist as soon as DKA is suspected

Inter-facility Pediatric Transfer Guideline
Inter-facility transfer guideline is defined as:11 hospital-to-hospital (including out of State/Territory) procedural and administrative policies for transferring critically ill children to facilities that provide specialized pediatric care, or pediatric services not available at the referring facility Components of a Pediatric Inter-facility transfer guidelines should include: Process for initiating a transfer the roles and responsibilities of the referring facility the roles and responsibilities of the referral center responsibilities for requesting transfer and communication Process for selecting an appropriate facility Process for selecting an appropriately staffed transport service Process for patient transfer In order to assure that children receive optimal care, timely transfer to a specialty care center is essential. Such transfers are better coordinated through the presence of inter-facility transfer agreements and guidelines. A performance measure defined by the Federal EMSC program requires all states to work to ensure that all hospitals in each state have written inter-facility transfer agreements and guidelines that cover pediatric patients. Transfer guidelines are defined by the Federal EMSC program that outline procedural and administrative policies for transferring critically ill children to facilities that provide specialized pediatric care, or pediatric services not available at the referring facility. It is recommended that hospitals should have transfer guidelines in place that include several key components. Those components include the process for initiating a transfer. The roles and responsibilities of the referring facility should be outlined, as well as the responsibilities for requesting transfer and communication. In addition, the guidelines should include a process for selecting an appropriate facility and appropriately staffed transport service for patient transfer. Those components will be discussed in the next several slides.

Transport: Selecting a Facility
Factors to consider when selecting the appropriate facility: PICU or pediatric unit specializing in diabetes care with: Written guidelines for DKA management in children A specialist with training and expertise in the management of DKA Experienced nursing staff trained in monitoring and management of DKA Access to laboratories for frequent and timely evaluation of critical labs Severely ill children may require specialized pediatric critical care services that are not generally available in community hospitals. Specialized pediatric referral centers provide 24-hour telephone consultation to assist community physicians in the evaluation and management of critically ill children. In addition, most of these referral centers provide pediatric inter-facility transport services to facilitate the transport of critically ill children to specialized centers when indicated. Factors to consider when selecting a facility should include access to a specialist with training and expertise in the management of DKA, experienced nursing staff trained in monitoring and management of DKA, and laboratories for frequent and timely evaluation of critical labs. A child in DKA should be managed in a PICU or pediatric unit specializing in diabetes care with equivalent resources and supervision, and written guidelines for DKA management in children. Timely transfer to a specialty care center is essential. Timely transfer to a specialty care center is essential

Transport: Mode of Transport
Process for selecting appropriate method of transport: The referring physician, in consultation with the receiving center, should: Determine the method of transport Use appropriate personnel to accompany the child Critical care transport team Transport staff matches child’s acuity Utilize appropriate sized equipment and medication If an inter-facility transport is required, the referring physician, in consultation with the receiving center, should determine the method of transport. A critical care transport team is needed when transporting the child in DKA, especially when an insulin infusion has already been initiated. The appropriate personnel should accompany the child on transport and should match the acuity of the child. The transport team should utilize appropriately sized equipment and medication at all times during transport. Use a specialized transport team for any child already started on an insulin infusion

Transport: Patient Transfer
Process for patient transfer: Obtain informed consent Plan transfer of: Medical record Copy of signed transport consent Personal belongings Provide family with receiving institution information and directions For all inter-facility pediatric transfers, an informed consent should be obtained. In addition, it is important to transfer all medical records. Provide the transport team with a copy of the most recent documentation before transfer and fax any additional information. A process should be in place to assure that personal belongings are provided to the family or accompany the child on transport. The family should also be provided with information and directions to the receiving institution. Inter-facility transfer guidelines are intended to assist hospital personnel in identifying children who might benefit from consultation and/or transfer to specialized pediatric critical care centers. The overall goal is to expedite safe transport of the child using trained staff with appropriate equipment and medications. The overall goal is to expedite safe transport of the child using trained staff with appropriate equipment and medications

COMPLICATIONS Return to Table of Contents
Now, we will review potential complications related to DKA management. Return to Table of Contents

DKA Management: Common Complications
Inadequate rehydration Hypoglycemia Hypokalemia In DKA management, inadequate rehydration, hypoglycemia and hypokalemia are the most common complications. Provided that they are detected and treated promptly, these rarely result in serious issues. Assume that most children with DKA are 3 to 5% dehydrated, so assure adequate rehydration takes place. Hypoglycemia can occur if bolus insulin is used or if blood glucose monitoring is not frequent enough. As acidosis is corrected, the potassium level decreases, which may reveal a pre-existing low potassium level.

DKA Management: Serious Complications
Cerebral Edema Pulmonary Edema CNS Hemorrhage or Thrombosis Cardiac Arrhythmias Pancreatitis Renal Failure More serious complications of DKA are rare, but include: cerebral edema, pulmonary edema, CNS hemorrhage or thrombosis, cardiac arrhythmias, pancreatitis, and renal failure. Cerebral edema due to DKA is almost exclusively a pediatric condition. Cerebral edema due to DKA is almost exclusively a pediatric condition

Unclear Pathogenesis DKA-related cerebral edema remains poorly understood Many theories proposed12,13,14,15 Data from literature has not clearly supported any particular theory Treatment causing or exacerbating cerebral edema has been particularly controversial Continues to be a topic of current review18,19 Many theories have been proposed to explain the pathogenesis of cerebral edema. However, the literature has not clearly supported any particular theory. Therefore, DKA-related cerebral edema remains poorly understood. The question of whether DKA treatment may play a role in causing or exacerbating cerebral edema has been particularly controversial. Recent data has provided evidence both for and against various theories of pathogenesis, and this is why it is still a topic of review.

Cerebral Edema: Facts Occurs in less than 1% of Pediatric DKA episodes
Accounts for 60% to 90% of all DKA deaths 10% to 25% of survivors have permanent neurological injury While cerebral edema occurs in less than 1% of Pediatric DKA episodes, it accounts for the majority of all DKA deaths. In addition, up to a quarter of survivors have permanent neurological injury.

Cerebral Edema: Presentation
May develop without warning symptoms Asymptomatic cerebral swelling is believed to occur more frequently Occurs most frequently 4-12 hours after therapy initiation May occur before treatment is initiated. Cerebral edema may develop without warning symptoms. In fact, asymptomatic cerebral swelling is believed to occur more frequently. Typically, cerebral edema occurs 4 to 12 hours after the initiation of therapy. However, it can present earlier or later, including before any treatment is initiated.

Cerebral Edema: Risk Factors
Younger age (e.g., infants and children < 5 yrs) New-onset diabetes High glucose levels Severe dehydration (elevated BUN/creatinine) Severe acidosis (lower pH, HCO3, pCO2) Treatment with bicarbonate Factors that may increase the risk for the development of cerebral edema include: new-onset diabetes; high glucose levels; severe dehydration with elevated BUN and creatinine levels; severe acidosis; and those treated with bicarbonate. In addition, it’s important to note that the mental status of infants and children less than five years of age may be more difficult to assess. For this reason, more frequent neurological evaluations of younger children would be warranted.

Cerebral Edema: Rate of Fluid Rehydration?
Controversial Issue Does a faster rate of rehydration increase risk of cerebral edema? 18,19 Should there be gradual, even fluid replacement during treatment? A few studies on causes of cerebral edema have suggested that a faster rate of rehydration and a rapid reduction in plasma osmolality increased the risk. Subsequent studies have not found that the rate of fluid administration is a factor for cerebral edema. This issue still remains very controversial. Currently, recommendations for a more gradual, even fluid replacement during the treatment of DKA are proposed. 18,19

Cerebral Edema: Warning Signs & Symptoms
Major criteria:13 Altered mental status/fluctuating LOC Sustained HR deceleration (not due to sleep or improved intravascular volume) Age-inappropriate incontinence Minor criteria: Vomiting Headache Lethargy Diastolic B/P  90 bpm Age  5 years The onset of cerebral edema is often gradual, with complaints of persistent headache, vomiting, and changes in vital signs such as slowing of the heart rate and elevated blood pressure. Symptoms progress to changes in neurological status including: restlessness, irritability, drowsiness and incontinence. Children with cerebral edema may present with a gradual decrease or deterioration in level of consciousness. However, a child may initially show a gradual general improvement, followed by sudden neurological deterioration. Clinical diagnosis of cerebral edema is based on major and minor diagnostic criteria as seen on this slide. A diagnosis is determined by the presence of either two major criteria, or one major and two minor criteria.

Cerebral Edema: Treatment
Reduce rate of intravenous fluids Elevate head of bed to at least a 30° angle Give mannitol gram/kg IV over 20 minutes May repeat if no initial response in 30 minutes to 2 hours Have mannitol ready at bedside and calculate dose beforehand Because cerebral edema occurs infrequently, data is limited regarding the effectiveness of pharmacological interventions for treatment of cerebral edema. Current recommendations when cerebral edema is suspected include: reduce the rate of intravenous fluids, elevate the head of bed to at least a 30 degree angle, and give mannitol, which is currently the standard of care. The dose is 0.25 to 1 gram per kilogram IV, administered over twenty minutes which may be repeated if no initial response is seen in thirty minutes to two hours. Have medications ready at the bedside with dosages calculated beforehand. Treatment should be initiated as soon as the condition is suspected. Initiate treatment as soon as cerebral edema is suspected

Cerebral Edema: Treatment (cont.)
Intubation for impending respiratory failure avoid aggressive hyperventilation CNS imaging studies (non-contrast CT scan) treatment should not be delayed while waiting results. Transfer and or admit to PICU. Intubation may be necessary for the patient with impending respiratory failure, but aggressive hyperventilation has been associated with poorer outcomes and is not recommended. Central nervous system imaging studies, such as a CT scan, are recommended to confirm the diagnosis and to rule out other causes of neurological deterioration. However treatment should not be delayed while waiting for results. Children with cerebral edema should be transferred and or admitted to the PICU for management. These measures may be life-saving when initiated promptly and may prevent neurologic sequelae. These measures may be life-saving when initiated promptly (before coma) and may prevent neurologic sequelae.

Key Points of Cerebral Edema
Cerebral edema as a complication of DKA is almost exclusively a condition of childhood The pathophysiology is still not completely understood Occurs most frequently 4-12 hours after therapy initiation Clinical diagnosis is based on major and minor criteria The clinical course is variable Let’s review the key points of cerebral edema as related to DKA management. Cerebral edema as a complication of diabetic ketoacidosis is almost exclusively a condition of childhood. The pathophysiology is still not completely understood. It usually occurs between 4 to 12 hours from the start of treatment, but may be present at the onset of DKA and can occur up to 24 hours later. The clinical diagnosis of cerebral edema is based on major and minor diagnostic criteria. A diagnosis is determined by the presence of two major criteria or one major and two minor criteria. The clinical course is variable. Children with cerebral edema may present with a gradual decrease or deterioration in level of consciousness, however a child may initially show a gradual general improvement followed by sudden neurological deterioration.

Key Points of Cerebral Edema (cont.)
Requires urgent recognition and intervention Treatment of choice is mannitol ( gram/kg) Requires admission to a PICU Intubation may be required, but hyperventilation should be avoided A non-contrast CT scan is needed to confirm the diagnosis of cerebral edema and to rule out other causes Cerebral edema requires urgent recognition and intervention. The treatment of choice is mannitol, which should be given immediately if cerebral edema is suspected. The child should be transferred or admitted to a PICU. While intubation may be required, hyperventilation should be avoided. A CT scan is needed to confirm the diagnosis and to rule out other causes.

PATIENT EDUCATION Return to Table of Contents
Education is an essential component in the prevention of DKA. Teaching survival skills to the child and family with diabetes is essential following correction of the DKA. This can be done in the pre-hospital or hospital setting, but must be done prior to discharge. Return to Table of Contents

DKA Can Be Prevented! Management of an episode of DKA is not
complete until the cause has been identified and an attempt made to prevent it. Better access to medical care Proper education Effective communication with health care provider It is important to note that the management of a DKA episode is not complete until the cause has been identified and preventative measures put in place to prevent it from occurring again. Many cases of DKA can be prevented by: better access to medical care, proper education, and effective communication with the primary health care provider. For new-onset diabetes, delayed diagnosis is often the cause for DKA. In most cases of established diabetics, insulin omission, either advertently or deliberately is typically the cause. The most common cause of DKA in insulin pump users is failure to take extra insulin with a pen or syringe when hyperglycemia and hyperketonemia occur.

How To Reduce Episodes Of DKA
All children and families with diabetes should receive comprehensive diabetes health care and education. Recognize the early warning signs and symptoms of ketoacidosis Take home measurements of blood ketone levels for earlier diagnosis Frequent insulin pump checks for blockages, kinks, or disconnections Have access to a 24-hour diabetes telephone help-line To reduce episodes of DKA, all children and families with diabetes should receive comprehensive diabetes health care and education. Families of children with diabetes should be instructed on warning signs and symptoms of ketoacidosis, and they should be encouraged to test blood ketone levels at home for earlier identification. In children with infections or who are on insulin pump therapy, measuring both urine and blood ketones can give more information than glucose measurements alone. Insulin pump users need to check often to see that insulin is still flowing through the tubing, and that there are no blockages, kinks, or disconnections. Most importantly, they must be able to communicate with a health care professional 24 hours a day.

Diabetic Education How to use a glucose monitoring device to check glucose levels How to draw up insulin and give injections How to recognize and treat hypoglycemia, including administration of glucagon Understand the basic principles of diet in terms of both content and timing of meals and snacks Basic diabetic education before hospital discharge should include: using a glucose monitoring device to check glucose levels, drawing up and administering insulin injections, recognizing and treating hypoglycemia, and use of glucagon. In addition, a basic understanding of the diabetic diet should be demonstrated.

Discharge Instructions
Before discharge: Meet with diabetes provider/educator and arrange follow-up Ensure child and family know when and where they are to return for follow-up care Prior to discharge, the child and family should meet with a diabetes educator. Basic discharge instructions should be given to the child and family members prior to discharge from either the ED or the inpatient unit. These instructions must include knowing who the medical practitioner is that they are to be in close contact with during the initial period of insulin adjustment and diabetes education. Also, they need to know when and where they are to return for follow-up care.

Sick Day Management: Overview
When to contact PCP/Endocrinolgist/Diabetic Educator Blood glucose goals Use of supplemental insulin during illness Medications to suppress fever and treat infections Initiation of an easily digestible liquid diet containing carbohydrates and salt MOST IMPORTANT Never discontinue or withhold insulin Seek professional advice early in the course of illness Sick day management should be reviewed periodically, and especially after an episode of DKA. Sick day management must include the following instructions: when to contact the primary care physician, Endocrinologist, or Diabetic Educator; blood glucose goals; the use of supplemental insulin during illness; medications to suppress fever and treat infections; and the initiation of an easily digestible liquid diet containing carbohydrates and salt. Most importantly, never discontinue or withhold insulin, and seek professional advice early in the course of the illness.

Sick Day Management: Basics
Successful sick day management must include: Involvement of the child Involvement of parent and family members The ability to measure blood glucose The ability to measure urine and/or blood ketones Knowledge of insulin administration Know how to take a temperature, respirations and pulse Know current weight Able to communicate signs and symptoms to health care professionals Every family member is affected when a child has DKA. Successful sick day management must include immediate and even extended family members. Successful sick day management involves following trends and responding to changes in the parameters listed on this slide. In addition, the caregiver will need to communicate this information to the child’s health care professionals.

Effective School-based Diabetes Management
Basic diabetes training for all staff Shared responsibilities for care, with leadership by school nurse Self management is allowed in all school settings for students with capacity These principles have been endorsed by the American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Association of Diabetes Educators, American Dietetic Association, Children with Diabetes Disability Rights Education Defense Fund, Juvenile Diabetes Research Foundation, Lawson Wilkins Pediatric Endocrine Society, and Pediatric Endocrine Nursing Society. For all students with diabetes, their management must occur 24 hours a day, 7 days a week, particularly the many hours spent at school, on field trips and in extra-curricular activities. Effective diabetes management at school and during school related activities requires a team approach including the family, the child’s diabetes health care provider and school personnel. Every team member plays a vital role in ensuring a safe and positive learning environment. Effective school-based diabetes management requires the following three components. First, basic diabetes training should be provided for all staff members that includes a basic understanding of the disease, how to identify medical emergencies, and which school staff members to contact with questions or in case of an emergency. Second, identify staff who will share responsibilities for care. Leadership should be provided by the school nurse who holds the primary role of coordinating, monitoring, and supervising the care of a student with diabetes. Third, self management should be allowed in all school settings for students who are capable of managing their own disease. Such self-management should include monitoring blood glucose and responding to abnormal levels as needed while utilizing appropriate treatment plans.

RESOURCES Return to Table of Contents
Now, we will introduce some helpful resources. Return to Table of Contents

Resources American Diabetes Association
The American Diabetes Association web site provides valuable information for both families and health care professionals on a variety of topics, including diabetes basics, living with diabetes, food and fitness planning, community programs and support, diabetes news and research. A special section is dedicated to diabetes care at school called “Safe at School.” The Children with Diabetes site is an online community for kids, families and adults with diabetes. It also provides chat forums to answer questions from an experienced team of diabetes health professionals. Children with Diabetes

Resources Children with Diabetes Foundation
European Society for Pediatric Endocrinology The Children with Diabetes Foundation promotes education and public awareness of the symptoms of diabetes and provides information on school-specific care. The European Society for Pediatric Endocrinology is an international professional organization whose aim is to promote the highest levels of knowledge, research, education, and clinical practice of pediatric endocrinology, including diabetes. The Lawson Wilkins Pediatric Endocrine Society is dedicated to research and treatment of children with endocrine disorders, including diabetes. It provides access to extensive materials for professionals, patients, and family members. Lawson Wilkins Pediatric Endocrine Society

Resources International Diabetes Federation
International Society for Pediatric and Adolescent Diabetes The International Diabetes Federation is tackling diabetes on many fronts, from the local to the global level, from community level programs to worldwide awareness and advocacy initiatives. The International Society for Pediatric and Adolescent Diabetes is a professional organization whose aim is to promote research, education and advocacy in childhood and adolescent diabetes. The Juvenile Diabetes Research Foundation is a leading charitable foundation and advocate for type 1 diabetes research worldwide. It provides a variety of information on living with diabetes. Juvenile Diabetes Research Foundation

American Diabetes Alert Day
Observed on the fourth Tuesday in March: American Diabetes Alert Day The American Diabetes Alert Day is a one-day, “wake-up” call to inform the American public about the seriousness of diabetes. An annual American Diabetes Alert Day is observed on the fourth Tuesday in March. This is a one-day, “wake-up” call to inform the American public about the seriousness of diabetes. Another aspect of the day is to strongly encourage every child to wear some type of medical alert identification for emergencies.

American Diabetes Month
November is American Diabetes Month A time to communicate the seriousness of diabetes and the importance of diabetes prevention and control. If current trends continue, one out of every three children born today will face a future with diabetes. November is American Diabetes month. It is a time to communicate the seriousness of diabetes and the importance of diabetes prevention and control. The Stop Diabetes movement encourages individuals to get involved by sharing, acting, learning and giving. 1 out of every 3 children born today will face a future with diabetes if current trends continue.

World Diabetes Day World Diabetes Day is celebrated worldwide to increase diabetes awareness and advocacy World Diabetes Day is celebrated every year on November 14. The World Diabetes Day campaign is led by the International Diabetes Federation and its member associations. It engages millions of people worldwide in diabetes advocacy and awareness. World Diabetes Day was created in 1991 by the International Diabetes Federation and the World Health Organization in response to growing concerns about the escalating health threat that diabetes now poses. The campaign draws attention to issues of paramount importance to the diabetes world, and keeps diabetes firmly in the public spotlight.

Test Your Knowledge Return to Table of Contents
The next several slides provide an opportunity for you to test your knowledge. Return to Table of Contents

Test Your Knowledge: School Nurse
You are a School Nurse at a local Elementary School. You are called to the classroom of a 10 year old female student. She is sitting at her desk slumped over the desktop, awake but drowsy. She feels nauseated and weak. She complains of abdominal pain and states that she hasn’t felt well for a few days. Respirations are deep and rapid and she has a fruity odor to her breath. Based on your assessment thus far which action should you choose? (1) The student’s breathing pattern and odor indicates a possible toxic ingestion, you call the poison center (2) The student’s breathing pattern and breath odor indicates a metabolic problem such as hyperglycemia, you check her blood glucose level (3) The student's breathing pattern indicates an foreign body airway obstruction , you apply abdominal thrusts (Heimlich Maneuver) (4) The student’s breathing pattern along with abdominal pain indicates an acutely inflamed abdomen, you perform an abdominal assessment For answer, proceed to next slide

The Correct Answer is…. (2) The student’s breathing patterns indicates a metabolic problem such as hyperglycemia. You should check her blood glucose level. Question Review If hyperglycemia is suspected, check the blood glucose level. Hyperglycemia is high blood glucose levels defined as greater than 200 mg/dL. It develops when the body has too much glucose in the blood. If left untreated can lead to complications such as DKA. Clinical presentation of DKA include: deep and rapid respirations, nausea, vomiting, fruity breath odor, abdominal pain, lethargy/drowsiness, and confusion.

Test Your Knowledge (cont.)
You have obtained base line vital signs: pulse 120, respirations 42, B/P 92/58 and a blood glucose level of 340 mg/dL. As you continue your assessment you notice further increase in respiratory rate and a deterioration in mental status. Based on this information, what would your next course of action be? (1) Contact parent or guardian to pick up child and seek medical advice (2) Continue to monitor vital signs and neurological status in nurses' office (3) Activate EMS (4) Provide student with something to drink For answer, proceed to next slide

The Correct Answer is…. (3) Activate EMS Question Review
You have identified a life-threatening problem and the need to activate EMS. As you await EMS arrival: Support airway, breathing and circulation as indicated Monitor vital signs and neurological status Repeat glucose level as necessary Give nothing by mouth Place in left lateral recovery position to prevent aspiration Prepare for transport and notify parent or guardian

For answers, proceed to next slide
Quiz 1. The most common symptom(s) of diabetes mellitus is (are): (a) headache, chest pain (b) frequent urination, hunger, thirst (c) craving for sweets (d) sweaty, nervous 2. The normal fasting blood glucose level is: (a) mg/dL (b) mg/dL (c) mg/dL (d) > 250 mg/dL 3. Which of the following is not an indicator of diabetic ketoacidosis: (a) very dry mouth (b) nausea/vomiting (c) slow and shallow breathing (d) lethargy/drowsiness 4. Precipitating factors in the development of DKA include: (a) missed insulin dose(s) (b) change in eating habits/diet (c) Stress and illness (d) all of the above 5. A Individualized Health Care Plan (IHP) is required for all students with diabetes in the school setting. (a) true (b) false For answers, proceed to next slide

Quiz Answer Key: 1. (b) 2. (c) 3. (c) 4. (d) 5. (a)TRUE
1. The most common symptom(s) of diabetes mellitus is (are): (a) headache, chest pain (b) frequent urination, hunger, thirst (c) craving for sweets (d) sweaty, nervous 2. The normal fasting blood glucose level is: (a) mg/dL (b) mg/dL (c) mg/dL (d) > 250 mg/dL 3. Which of the following is not an indicator of diabetic ketoacidosis: (a) very dry mouth (b) nausea/vomiting (c) slow and shallow breathing (d) lethargy/drowsiness 4. Precipitating factors in the development of DKA include: (a) missed insulin dose(s) (b) change in eating habits/diet (c) Stress and illness (d) all of the above 5. A Individualized Health Care Plan (IHP) is required for all students with diabetes in the school setting. (a) true (b) false Answer Key: 1. (b) 2. (c) 3. (c) 4. (d) 5. (a)TRUE

Test Your Knowledge: Pre-hospital Professional
You are a pre-hospital professional dispatched to the home of a 6 year old male with sudden onset of lethargy and vomiting. You are advised that the child is conscious and breathing. According to the mother, "He suddenly became ill several hours ago and has gotten worse since then.” He has a known history of diabetes and recently was placed on a insulin pump for insulin administration. While enroute to the scene, you review the complications of diabetes with your partner. Which of the following statements are true? (1) Diabetic emergencies are generally related to extremely high or low blood glucose levels (2) Diabetic emergencies may occur with no identifiable predisposing factor (3) Altered mental status is often caused by complications of diabetes (4) All of the above For answer, proceed to next slide

The Correct Answer is…. (4) All of the above Question Review
Diabetic emergencies are generally related to extremely high or low blood glucose levels Children at risk for diabetic emergencies are those lacking medical supervision and/or insufficient insulin administration Diabetic emergencies may occur with no identifiable predisposing factor Altered mental status is often caused by complications of diabetes Question Review Most emergencies in children with established diabetes are related to events of hypoglycemia or hyperglycemia. Risk factors include: younger children, improper medical supervision or poor diabetes control. These emergencies are generally due to missed insulin injections and insulin pump failures. There may be no identifiable predisposing factor. It is not uncommon for children with complications of diabetes to present with symptoms of altered mental status.

Test your Knowledge (cont.)
On arrival the child is conscious but clearly appears ill. Upon assessment you determine he is tachycardic, has deep rapid respirations, signs of dehydration and an altered level of responsiveness. The mother states the blood glucose pump recordings have indicated normal values. What intervention would you do next? (1) Apply C-spine immobilization (2) Place on cardiac monitor (3) Obtain blood glucose level (4) Administer glucagon For answer, proceed to next slide

The Correct Answer is…. (3) Obtain blood glucose level Question Review
Although the mother has indicated normal blood glucose values, it is best to obtain a blood glucose level upon arrival to determine an accurate baseline level. This will allow you to determine, in an instant, if your interventions will be based on either hypoglycemia or hyperglycemia.

Test your Knowledge (cont.)
The blood glucose level obtained is 420 mg/dL. You have determined this child to have severe hyperglycemia. Because of his signs of dehydration, deep, rapid respirations and altered mental status, you are concerned that he is progressing into DKA. What further management is indicated now? Remember, treatment priorities will depend on the pre-hospital professional level. Choose the answer(s) that best match the level of the pre-hospital professional. The treatment priorities for this patient are: (1) Support airway, breathing and circulation if indicated (2) Give nothing by mouth and apply O2 (3) Transport immediately to appropriate hospital per medical control and continue to monitor vital signs and mental status (4) All of the above For answer, proceed to next slide

Support airway, breathing and circulation if indicated Give nothing by mouth and apply O2 Transport immediately to appropriate hospital per medical control and continue to monitor vital signs and mental status Question Review Children presenting in DKA are a medical emergency, therefore the goal of the pre-hospital professional is to safely transport to the closest appropriate care center in a timely fashion. The level of the pre-hospital professional will determine the type of care that can be provided. Always perform ongoing assessments to observe the response to interventions and to guide changes in treatment, transport and triage. Maintain contact with medical control, which allows for complete and concise transmission of vital data. In turn this allows the ED team to best prepare for the child’s arrival.

Quiz 1. Which statement is not correct when defining Type 1 diabetes: (a) non-insulin dependent (b) body does not produce insulin (c) diagnosed in children and young adults (d) insulin dependent 2. Which of the following signs and symptoms are associated with DKA: (a) decreased LOC, recent seizure, normal vital signs (b) dry skin, slow respirations, normal heart rate (c) decreased LOC, tachycardia, deep and rapid respirations (d) sweaty skin, tachycardia, rapid respirations 3. Prolonged and exceptionally high hyperglycemia may lead to: (a) ketosis (b) acidosis (c) DKA (d) all of the above 4. Signs of dehydration may include: (a) prolonged capillary refill and poor skin turgor (b) abnormal breathing and altered mental status (c) Dry mucus membranes and warm skin (d) all of the above 5. All children and families with diabetes should receive comprehensive diabetes health care and education: (a) true (b) false For answers, proceed to next slide

Quiz Answer Key: 1. (a) 2. (c) 3. (d) 4. (d) 5. (a) TRUE
1. Which statement is not correct when defining Type 1 diabetes: (a) non-insulin dependent (b) body does not produce insulin (c) diagnosed in children and young adults (d) insulin dependent 2. Which of the following signs and symptoms are associated with DKA: (a) decreased LOC, recent seizure, normal vital signs (b) dry skin, slow respirations, normal heart rate (c) decreased LOC, tachycardia, deep and rapid respirations (d) sweaty skin, tachycardia, rapid respirations 3. Prolonged and exceptionally high hyperglycemia may lead to: (a) ketosis (b) acidosis (c) DKA (d) all of the above 4. Signs of dehydration may include: (a) prolonged capillary refill and poor skin turgor (b) abnormal breathing and altered mental status (c) Dry mucus membranes and warm skin (d) all of the above 5. All children and families with diabetes should receive comprehensive diabetes health care and education: (a) true (b) false Answer Key: 1. (a) 2. (c) 3. (d) 4. (d) 5. (a) TRUE

Test Your Knowledge: Emergency Department
A lethargic child is rushed into the emergency department by her mother who states that she was unable to arouse her four-year-old from bed this morning. She reports that her child had appeared “totally fine” until last evening when her daughter complained of some “belly pain” and experienced several episodes of vomiting. The mother denies a history of trauma and states that her child has no medical problems. The child is not taking any medications, has no known allergies, and has had no recent contact with any communicable diseases. Components of your assessment should include ? (1) Evaluate the ABC’s; airway, breathing and circulation (2) Obtain vital signs, weight (kg), and point-of-care testing (BGL/urine ketones) (3) Assess clinical severity of dehydration (4) Assess neurological status (5) Place child on cardiac monitor (6) All of the above For answer, proceed to next slide

The Correct Answer is…. (6) All of the above
Evaluate the ABC’s; airway, breathing and circulation Obtain vital signs, weight (kg), and point-of-care testing (BGL/urine ketones) Assess clinical severity of dehydration Assess neurological status Place on cardiac monitor Question Review DKA is a medical emergency, and as in common with all emergencies: Resuscitation should follow the “ABC” pattern (airway, breathing and circulation). Obtain vital signs Weigh the patient, in kilograms. If body surface area is used for fluid therapy calculations, measure height or length to determine surface area. This weight should be used for calculations and not a weight from a previous office visit or hospital record. Obtain point-of-care testing Blood glucose and urine ketones All children with DKA require supplemental fluids due to dehydration. DKA fluid deficit is usually in the range of 5-10% Utilizing assessment tools such as AVPU or the Pediatric Glasgow Coma Scale (PGCS) may help to detect early signs of cerebral edema Assess cardiac rhythm Monitoring to assess for arrhythmias and for presence of abnormal T waves, which would indicate hypokalemia or hyperkalemia..

The child is presumed to be in DKA, the following is initiated: Non-rebreather mask at L/minute Continuous cardiac monitor Pulse oximeter A peripheral venous catheter access Initial labs Fluid resuscitation What is the goal of the first hour of treatment for DKA? (1) Replace potassium deficits (2) Volume resuscitation and confirmation of DKA by laboratory studies (3) Initiation of an insulin drip (4) All of the above For answer, proceed to next slide

The Correct Answer is…. (2) Volume resuscitation and confirmation of DKA by laboratory studies Question Review Management of DKA starts with intravenous fluid replacement. The goal of the first hour of treatment is volume resuscitation and confirmation of DKA by results of laboratory studies. Insulin treatment is begun after the initial fluid resuscitation; that is, at the beginning of the second hour of therapy. Beginning insulin treatment at the same time as fluid resuscitation increases the risks of severe hypokalemia, and of rapidly and excessively decreasing the serum glucose.

The child is confirmed to be in DKA. Phase I, initial volume expansion has been initiated. The clinical status of the child appears to be deteriorating. Continued ED management of a child in DKA would include? (1) Continue to monitor and follow your hospital DKA protocol (2) Consult with Pediatric Endocrinologist and/or Intensivist for treatment options (3) Begin admission process to your hospital’s PICU or transfer to a receiving hospital with a higher level of care (4) All of the above For answer, proceed to next slide

Continue to monitor and follow your hospital DKA protocol Consult with Pediatric Endocrinologist and/or Intensivist for treatment options Begin admission process to your hospital’s PICU or transfer to a receiving hospital with a higher level of care Question Review Once DKA is suspected and/or confirmed, early consultation with a Pediatric Endocrinologist and/or Intensivist regarding management and treatment is strongly recommended. Severely ill children, those in DKA may require specialized pediatric critical care services that may not be available in the ED. For those reasons, begin admission process to your hospital’s PICU or transfer to a receiving hospital with a higher level of care. In addition, it is important to continue to monitor the child based on your hospital’s DKA protocol and guidelines.

Quiz 1. The biochemical criteria for the diagnosis of DKA is defined as: (a) blood glucose greater than 200 mg/dl (b) ketones present in blood and/or urine (c) ph less than 7.3 and/or bicarbonate less than 15 mmol/L (d) all of the above 2. Blood test used to diagnose the presence and severity of acidosis include: (a) only arterial blood gases (b) arterial blood gas or venous blood gas and electrolytes (c) electrolytes and serum β-hydroxybutyrate (d) blood glucose, urine ketones and electrolytes 3. Complications of DKA management are: (a) inadequate rehydration (b) hypoglycemia (c) cerebral edema 4. First hour management of a child suspected of DKA would be: (a) give IV fluid of 0.9% NS at maintenance (b) give an IV bolus of 0.9% NS mL/kg over the first hour (c) administer insulin bolus (d) wait for more laboratory results before giving any fluids or insulin 5. Pediatric Glasgow Coma Scale (PGCS) is an accurate measure to document level of consciousness over a period of time (a) true (b) false For answers, proceed to next slide

Quiz Answer Key: 1. (d) 2. (b) 3. (d) 4. (b) 5. (a) TRUE
1. The biochemical criteria for the diagnosis of DKA is defined as: (a) blood glucose greater than 200 mg/dl (b) ketones present in blood and/or urine (c) ph less than 7.3 and/or bicarbonate less than 15 mmol/L (d) all of the above 2. Blood test used to diagnose the presence and severity of acidosis include: (a) only arterial blood gases (b) arterial blood gas or venous blood gas and electrolytes (c) electrolytes and serum β-hydroxybutyrate (d) blood glucose, urine ketones and electrolytes 3. Complications of DKA management are: (a) inadequate rehydration (b) hypoglycemia (c) cerebral edema 4. First hour management of a child suspected of DKA would be: (a) give IV fluid of 0.9% NS at maintenance (b) give an IV bolus of 0.9% NS 10-20 mL/kg over the first hour (c) administer insulin bolus (d) wait for more laboratory results before giving any fluids or insulin 5. Pediatric Glasgow Coma Scale (PGCS) is an accurate measure to document level of consciousness over a period of time (a) true (b) false Answer Key: 1. (d) 2. (b) 3. (d) 4. (b) 5. (a) TRUE

REFERENCES Return to Table of Contents
The references for this module are listed on the next several slides, which are then followed by resource information in the appendices. Return to Table of Contents

References Wolfsdorf J, Glaser N, Sperling MA; American Diabetes Association. Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement from the American Diabetes Association. Diabetes Care. 2006;29(5): Dunger DB, Sperling MA, Acerini CL, et al. European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society consensus statement on diabetic ketoacidosis in children and adolescents. Pediatrics. 2004;113(2):e133–e140. Wolfsdorf J, Craig ME, Daneman D, et al. ISPAD Clinical Practice Consensus Guidelines 2009 Compendium. Diabetic ketoacidosis in children and adolescents with diabetes. Pediatric Diabetes. 2009;10(Suppl. 12):118–133. Kitabchi AE, Umpierrez GE, Murphy MB, et al. American Diabetes Association. Hyperglycemic crises in diabetes. Diabetes Care. 2004;27(Suppl. 1):S94-S102. Dean H, Sellers E, Kesselman M. Acute hyperglycemic emergencies in children with type 2 diabetes. Paediatr Child Health. 2007;12(1):43-44.

References Glaser NS, Barnett P, McCaslin I, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. N Engl J Med. 2001;344(4): Assal JP, Aoki TT, Manzano FM, Kozak GP. Metabolic effects of sodium bicarbonate in management of diabetic ketoacidosis. Diabetes. 1974;23:405– 411. Ohman JL Jr, Marliss EB, Aoki TT, et al. The cerebrospinal fluid in diabetic ketoacidosis. N Engl J Med. 1971;284:283–290. Edge J, Jakes R, Roy Y, et al. The UK prospective study ofcerebral oedema complicating diabeticketoacidosis. Arch Dis Child. 2005;90 (Suppl. 11):A2–A3. Narins RG, Cohen JJ. Bicarbonate therapy for organic acidosis: the case for its continued use. Ann Intern Med. 1987;106:615–618. Performance Measures: An Implementation Manual for State Partnership Grantees, 2009 Edition (pg ). Retrieved October 22, 2011 from

References Glaser NS, Cerebral injury and cerebral edema in children with diabetic ketoacidosis: could cerebral ischemia and reperfusion injury be involved? Pediatr Diabetes. 2009;10: Muir AB, Quisling RG, Yang MCK, Rosenbloom AL. Cerebral edema in childhood diabetic ketoacidosis: Natural history, radiographic findings and early identification. Diabetes Care. 2004;27(7): Bohn D. Understanding the pathophysiology of cerebral edema in diabetic ketoacidosis: Another brick in the wall? Pediatr Crit Care Med. 2010;11(3): Levin DL. Cerebral edema in diabetic ketoacidosis. Pediatr Crit Care Med. 2008;9(3): Poirier MP, Greer D, Satin-Smith M. A prospective study of the “two-bag system” in diabetic ketoacidosis management. Clin Pediatr. 2004;43: Grimberg A, Cerri RW, Satin-Smith M, Cohen P. The "two bag system" for variable intravenous dextrose and fluid administration: Benefits in diabetic ketoacidosis management. J Pediatr. 1999;134:

References Glaser NS, Wooton-Gorges SL, Buonocore MH, et al. Subclinical Cerebral Edema in Children with diabetic ketoacidosis randomized to 2 different rehydration protocols. Pediatrics. 2013;131(1):e73-e80. Glaser NS, Ghetti S, Casper TC, et al. Pediatric diabetic ketoacidosis, fluid therapy, and cerebral injury: the design of a factorial randomized controlled trial. Pediatr Diabetes. 2013;14:

APPENDIX A: ASSESSMENT TOOLS
Appendix A provides several useful assessment tools that may be utilized during the assessment process. Return to Table of Contents Return to slide 38

Systematic Assessment
Scene safety assessment Ensure that it’s safe to approach, or call for backup assistance as necessary. Pediatric Assessment Triangle (PAT) Immediately activate EMS if the situation is obviously emergent. Initial assessment (ABCDE) Identify and treat problems that threaten life. History Gather background information essential to your triage decision. Focused physical examination (FGHI) Measure and record vital signs, inspect, auscultate, and palpate to identify or investigate additional problems. A systematic assessment can be broken down into 5 major components, each of which has a specific role in emergency care. Scene safety assessment is used to ensure that the scene environment is safe to approach. Contact backup assistance, as appropriate, if the scene has any potential safety risks. In the across-the-room assessment, one obtains a general impression of the patient from a distance. Immediately activate EMS if the situation is obviously emergent. The initial assessment helps identify and treat problems that threaten life. The initial assessment is comprised of Airway, Breathing, Circulation, Disability and Exposure. Moving on through your assessment, the history is next and will enable you to gather background information essential to determining the appropriate triage category to assign. The focused physical examination aids in measuring and recording vital signs, along with inspection, auscultation, and palpation to identify or investigate additional problems. The FGHI of the focused physical examination stands for Full set of vital signs, Give comfort measures, head-to-toe assessment, and Isolate. EMSC School Nurse Emergency Care Course Manual Fourth Edition Return to slide 38

Pediatric Assessment Triangle
A quick overall appraisal of the child’s condition based on appearance, breathing and circulation Appearance Work of Breathing Tone, Interactiveness, Consolability, Look/Gaze, Speech/Cry Abnormal Airway Sounds (stridor, wheezing, grunting) Abnormal Positioning, Retractions, Flaring The Pediatric Assessment Triangle, known as PAT, is a tool used for an across-the-room assessment. It is a quick overall appraisal of the child’s general condition based on their appearance, breathing, and circulation. While approaching the child, briefly evaluate their appearance, work of breathing, and skin circulation. This allows you to determine, in a few moments, how quickly you must proceed with further assessments and interventions. The PAT allows you to simply form an overall impression of vital functions. Circulation To Skin Pallor, Mottling, Cyanosis Return to slide 38

Initial ABCDE Assessment
The initial assessment focuses on Airway, Breathing, Circulation, Disability (or neurologic status), and a brief physical Exposure to examine parts of the body directly related to the chief complaint. This slide provides an overview of each component in the initial assessment. As you interpret your assessment findings, keep in mind that many factors besides illness or injury can contribute to deviations from the norm. It is important to be aware of these factors, for example, certain medications can cause the breathing rate and heart rate to be fast or slow. A cold ambient temperature can delay capillary refill and affect other skin findings. Fear, fever, and pain typically increase the respiratory rate and heart rate. During the initial assessment, however, you are primarily looking for overt discrepancies indicative of a life-threatening or significant condition. If none are present, you then can move on to assessing less obvious signs during the focused physical examination. Remember, the goal of the initial assessment is to quickly identify and treat life-threatening emergencies. EMSC School Nurse Emergency Care Course Manual Fourth Edition Return to slide 38

Focused Physical Examination FGHI
The focused physical examination may be limited or involve a complete head-to-toe assessment depending on the circumstances. It begins with F which correlates with obtaining a full set of vital signs. At minimum, you will measure and document a full set of vital signs including blood pressure, heart rate, respiratory rate, and temperature. If possible, note weight and pulse-oximetry as well. G is aimed at giving comfort measures and performing interventions to alleviate pain. H is for conducting a limited or more focused assessment on a specific area, or completing a head-to-toe assessment using inspection, palpation and auscultation. You may need to perform specialized assessment procedures as indicated. Lastly, I stands for isolate, injuries and additional interventions. Assess the potential for communicable disease and isolate as indicated. Assess for injuries. And provide additional interventions based on your findings. EMSC School Nurse Emergency Care Course Manual Fourth Edition Return to slide 38

Systematic Assessment
Triage (E-U-N) Systematic Assessment EMERGENT NON-URGENT URGENT Emergent – child requires immediate medical attention. Condition is acute and has the potential to threaten life. Urgent – child requires additional medical intervention within 2 hours. Condition is acute but not severe or life threatening. Non-urgent – child may require referral for routine medical care. Minor or non-acute condition. Triage The three commonly recognized triage categories are emergent, urgent and non-urgent. Emergent refers to a condition that requires immediate medical attention. The condition is acute and has the potential to threaten life, limb or vision. Urgent refers to a condition that requires additional medical intervention within a 2 hour timeframe. The condition is acute but not severe or life threatening. Lastly, the Non-urgent category refers to a minor or non-acute condition. The child may require referral for routine medical care. Return to slide 38

Emergency Severity Index (ESI)
Five-level triage instrument Categorizes emergency department patients by patient acuity resources ESI 1 requires immediate life-saving intervention ESI 2 high risk situation: should the patient wait? ESI 3 vital signs: vital signs outside accepted parameters? ESI 4 resources prediction: how many resources are needed? ESI 5 no resources needed The Emergency Severity Index, known as ESI, is a triage system to use that is based on a five-level triage instrument. It assists in categorizing emergency department patients by evaluating both patient acuity and resource needs. Initially the triage nurse assesses only the acuity level. A high acuity level is consistent with an assigned ESI level of 1 or 2. If a patient does not meet high acuity level criteria, the triage nurse then evaluates expected resource needs to help determine a triage level of 3, 4, or 5. For example, for a level 3 ESI correlates with three or more resources needed such as labs, EKG, and IV fluids. An ESI of 4 needs only one resource, such as an x-ray, while an ESI of 5 is the least urgent and needs no resources. An example is a medication refill. Inclusion of resource needs into the triage rating is a unique feature of the ESI in comparison with other triage systems. Acuity is determined by the stability of vital functions and potential for life, limb, or organ threat. Resource needs are defined as the number of resources a patient is expected to consume in order for a disposition decision to be reached. By estimating the resource needs based on previous experience with patients presenting with similar injuries or complaints, the triage nurse can rapidly and accurately triage patients into one of the five levels. Source: ©ESI Triage Research Team, 2004 Return to slide 38

AVPU The AVPU scale should be assessed using these identifiable traits, looking for the best response of each A Alert - the child is lucid and fully responsive, can answer questions and see what you're doing. Infants – active, responsive to parents and interacts appropriately with surroundings V Voice - the child or infant is not looking around; responds to your voice, but may be drowsy, keeps eyes closed and may not speak coherently, or make sounds. P Pain - the child or infant is not alert and does not respond to your voice. Responds to a painful stimulus, e.g., shaking the shoulders or possibly applying nailbed pressure. U Unresponsive - the child or infant is unresponsive to any of the above; unconscious. The AVPU scale, which stands for Alert, Voice, Pain, Unresponsive is a system by which a first responder, ambulance crew, or health professional can measure and record a child’s level of consciousness. The AVPU scale should be assessed using these identifiable traits, looking for the best response in each. A stands for ALERT. In this category, the child is lucid and fully responsive, can answer your questions and can see what you're doing. In the infant, they appear active, are responsive to their parents and interact appropriately with their surroundings. V is for VOICE. The child or infant responds to your voice, but may be drowsy. They are not looking around, they keep their eyes closed and may not speak coherently or make sounds. P is for PAIN, the child is not alert and does not respond to your voice, but does respond to a painful stimulus, such as shaking the shoulders or possibly applying pressure to a nailbed. U is for UNRESPONSIVE. This child is unresponsive to any of the above and are unconscious. Pre-hospital personnel may begin with an AVPU assessment which then should be followed by a Pediatric Glasgow Coma Scale assessment if the AVPU score is below A. The AVPU scale is not suitable for long-term neurological observation of the child. In this situation the Pediatric Glasgow Coma Scale is more definitive and appropriate. The AVPU scale is not suitable for long-term neurological observation of the child. In this situation, the Pediatric Glasgow Coma Scale is more appropriate Return to slide 38

Pediatric Glasgow Coma Scale (PGCS)
The Pediatric Glasgow Coma Scale, known as PGCS, is an accurate measure to document level of consciousness over a period of time. Frequent assessment will indicate the progression and severity of the illness. The lower the score, the more severe the condition. The PGCS score quantifies level of consciousness using 3 functional parameters: alertness or eye opening, major CNS motor pathways as demonstrated by best motor response, and mentation as demonstrated by best verbal response. Calculating a baseline PGCS score and then reassessing the score as part of ongoing monitoring makes it easier to track changes in the child’s neurologic state. To determine the PGCS score, assign the most appropriate score in each of the 3 components. Then add up the scores from each component. The possible total score ranges from 3 to 15 points. A score lower than 9 indicates severe impairment, a score of 9 to 12 indicates moderate impairment and a score of 13 to 15 indicates minor impairment or normal function. Note that a child with a score of 13 to 15 may still have neurologic abnormalities that can progress to a life-threatening condition. For an accurate assessment of a child’s condition, always interpret PGCS scores in conjunction with other clinical findings. PGCS is an accurate measure to document level of consciousness over a period of time. Frequent assessment will indicate the progression of illness and determine it’s severity. The lower the score the more severe the illness. Return to slide 38

APPENDIX B: “Two-Bag System”
Next we will discuss a system called the “two-bag system.” Due to the specialty resources which are needed for this system, it should only be utilized in tertiary care centers. NOTE: The “two-bag system” should be used with caution and utilized only in tertiary care centers that have the necessary resources, including a Pediatric Endocrinologist on staff. The “two-bag system” should only be administered by staff who have been trained and have demonstrated competency. All IV fluids used in this method should be prepared by trained pharmacy personnel. Return to Table of Contents

Alternative Method to Administer Dextrose in Pediatric Tertiary Care Centers
The “two-bag system” is an alternate method for administering dextrose in tertiary care centers Consists of simultaneous administration of two IV fluids of differing dextrose concentrations Allows a more rapid response to changes in blood glucose concentration16 Rates of administration of the two bags of fluid can be adjusted to vary the dextrose concentration while maintaining a constant overall rate of fluid and other electrolyte administration NOTE: The “two-bag system” should be used with caution and utilized only in tertiary care centers that have the necessary resources, including a Pediatric Endocrinologist on staff. The “two-bag system” should only be administered by staff who have been trained and have demonstrated competency. All IV fluids used in this method should be prepared by trained pharmacy personnel. An important principle in the management of children in DKA is individualization of therapy, with careful monitoring of fluids, electrolytes, and serum glucose balance being a priority. The initial acute care of these children can be labor intensive, requiring frequent modifications of IV fluid therapy in order to adapt to fluctuations in fluid, electrolyte and dextrose needs. An alternative method to conventional single-bag administration of dextrose in the DKA patient is called the “two-bag system.” This system consists of simultaneous administration of two intravenous fluids of differing dextrose concentrations, allowing a more rapid response to changes in blood glucose concentrations. Individualized therapy is dictated by adjustment of the infusion rate of each bag. The relative rates of administration of the 2 fluids can be adjusted to vary the dextrose concentration while maintaining a constant overall rate of fluid and other electrolyte administration. This system enables a faster response time in making IV fluid therapy changes. However the “two-bag system” should be used with caution and utilized only in tertiary care centers that have the necessary resources, including a Pediatric Endocrinologist on staff. In addition, the “two-bag system” should only be administered by staff who have received appropriate training and who demonstrate ongoing competency. Trained pharmacy personnel should be responsible for preparing all intravenous fluids used in the administration of the “two-bag system.”

“Two-Bag System” EXAMPLE17
Two IV fluid bags are ordered from the pharmacy with identical electrolyte concentration Bag 1 will contain no dextrose Bag 2 will contain D10 Begin the initial infusion with Bag 1 only. IV fluid administration will initially contain no dextrose. Then adjust each bag accordingly. Increase dextrose by increasing the rate of Bag 2 and decreasing the rate of Bag 1 Decrease dextrose by decreasing the rate of Bag 2 and increasing the rate of Bag 1 The relative rates of administration of the two IV fluid bags are adjusted to change the dextrose concentration delivered to the patient while keeping fluid and electrolyte replacement constant The “two-bag system” is a convenient way to make the necessary adjustments in intravenous fluid and dextrose infusion rates. This slide shows an example of the “two-bag system.” The initial step is to contact pharmacy for two bags of intravenous fluids containing identical electrolyte concentrations. The first bag will not contain any dextrose, while the second bag in this example contains ten percent dextrose. Intravenous management typically begins by infusing only the non-dextrose solution initially. Then, each bag is adjusted accordingly based on the calculated fluid rate and the amount of dextrose that is needed. The relative rates of administration of the two intravenous fluid bags are adjusted to increase or decrease the dextrose concentration being delivered, while the fluid and electrolyte replacement, and total infusion rate is kept constant. Grimberg A, Cerri RW, Satin-Smith M, Cohen P. The "two bag system" for variable intravenous dextrose and fluid administration: Benefits in diabetic ketoacidosis management. J Pediatr. 1999;134:

“Two-Bag System” Key Points
Use with caution in tertiary care center settings with specialty resources Pediatric Endocrinologist on staff Pediatric Intensivist Trained staff with ongoing competency demonstration Trained pharmacy staff Provides more precise control of total fluid, electrolyte, and dextrose Tailors the IV fluids to meet the child’s individual needs Decreases time to institute ordered changes in fluid therapy Cost-effective “Two-bag system” costs less per DKA admission than one bag system Although the “two-bag system” has many advantages, it is important to remember that it should be used with caution and utilized only in tertiary care centers that have the necessary resources, including a Pediatric Endocrinologist and Pediatric Intensivist on staff. In addition, the “two-bag system” should only be administered by staff who have received appropriate training and who demonstrate ongoing competency. Trained pharmacy personnel should be responsible for preparing all intravenous fluids used in the administration of the “two-bag system.” Although there are several benefits to using the “two-bag system” over traditional methods of insulin administration, safe administration should always be the first priority. The advantages to using the “two-bag system” are that it provides more precise control of the total fluid, electrolyte, and dextrose administration. This system also allows for tailoring of the IV fluids to meet the child’s individual needs and decreases the turnaround time in instituting new physician order changes in fluid therapy. When used appropriately, the “two-bag system” results in less intravenous fluid bag changes than the traditional single bag system. Studies comparing the “two-bag system” to the traditional single bag system have shown it to be a more cost-effective method per DKA patient admission.

APPENDIX C: Treatment Guidelines
Appendix C contains examples of treatment guidelines. Return to Table of Contents

Treatment Guidelines Below are examples of Pediatric DKA guidelines that can be used as templates as you develop your own ED guidelines. Please give appropriate credit to any resource you utilize. Northwest Community Hospital (Arlington Heights, IL) Pediatric DKA Emergency Department Administrative Policy OSF St. Francis, Children’s Hospital of Illinois (Peoria, IL) Pediatric DKA Admission Guidelines Pediatric DKA Nursing Care Guidelines St. John’s Hospital (Springfield, IL) Treatment Flow Chart for DKA Management in the Emergency Department

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Pediatric Hyperglycemia and Diabetic Ketoacidosis (DKA)

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Pediatric Hyperglycemia and Diabetic Ketoacidosis (DKA)

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